=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992389480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA T RIZZO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2021
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 MEDICAL DR STE D
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-928-7922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 MEDICAL DR STE D
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-928-7922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 334232
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------