Healthcare Provider Details

I. General information

NPI: 1245346790
Provider Name (Legal Business Name): WILLIAM B KRISSOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10051 LAKE AVE SUITE 4
TRUCKEE CA
96161-4825
US

IV. Provider business mailing address

10051 LAKE AVE SUITE 4
TRUCKEE CA
96161-4825
US

V. Phone/Fax

Practice location:
  • Phone: 530-582-0202
  • Fax: 530-582-0206
Mailing address:
  • Phone: 530-582-0202
  • Fax: 530-582-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberG26823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: