Provider Demographics
NPI:1104963842
Name:RISMA, RUSSELL E (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:RISMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 SHEFFIELD CIR W
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1636
Mailing Address - Country:US
Mailing Address - Phone:970-310-5302
Mailing Address - Fax:
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29184207RA0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64744Medicare ID - Type Unspecified
COA16155Medicare UPIN