Healthcare Provider Details

I. General information

NPI: 1932344389
Provider Name (Legal Business Name): MICHAEL NISSEN, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 3RD AVE GROUND FLOOR
NEW YORK NY
10021-2995
US

IV. Provider business mailing address

1317 3RD AVE GROUND FLOOR
NEW YORK NY
10021-2995
US

V. Phone/Fax

Practice location:
  • Phone: 212-772-7000
  • Fax: 212-772-7001
Mailing address:
  • Phone: 212-772-7000
  • Fax: 212-772-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number188503
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number188503
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL NISSEN
Title or Position: PRESIDENT
Credential: MD
Phone: 212-772-7000