Healthcare Provider Details

I. General information

NPI: 1528190972
Provider Name (Legal Business Name): FRED D RISSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 CEDAR ST
BANGOR ME
04401-6433
US

IV. Provider business mailing address

44 SILVER RDG
VEAZIE ME
04401-7084
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-0366
  • Fax:
Mailing address:
  • Phone: 207-947-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number014652
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: