Healthcare Provider Details

I. General information

NPI: 1407817224
Provider Name (Legal Business Name): SUSAN C. RISTOW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 08/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ALEXANDER ST SUITE 402
ROCHESTER NY
14607-4008
US

IV. Provider business mailing address

540 ANTLERS DR
ROCHESTER NY
14618-2128
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-8350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number122410
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: