Provider Demographics
NPI:1407880503
Name:RISINGER, DAVID OWEN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:OWEN
Last Name:RISINGER
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 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3194
Mailing Address - Country:US
Mailing Address - Phone:817-321-0404
Mailing Address - Fax:817-321-0390
Practice Address - Street 1:815 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2224
Practice Address - Country:US
Practice Address - Phone:817-321-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH70932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1343360-05Medicaid
TX134336008Medicaid
TX1343360-05Medicaid
TX84R123Medicare PIN
TX8555M3Medicare PIN
TX300099849Medicare PIN
TX300122024Medicare PIN