Provider Demographics
NPI:1174571004
Name:RISEN, MARK A (DPM)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:RISEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1003 OLD GREENSBURG RD.
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718
Mailing Address - Country:US
Mailing Address - Phone:270-433-5806
Mailing Address - Fax:270-433-2443
Practice Address - Street 1:1003 OLD GREENSBURG RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2571
Practice Address - Country:US
Practice Address - Phone:270-433-5806
Practice Address - Fax:270-433-2443
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00216213E00000X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80002165Medicaid
0796001Medicare UPIN
KY1212820001Medicare NSC