Basic Information
| Provider Information | |||||||||
| NPI: | 1669527925 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RISTICH | ||||||||
| FirstName: | MIODRAG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 SUNRISE LN | ||||||||
| Address2: | |||||||||
| City: | UPPER SADDLE RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074581631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019345513 | ||||||||
| FaxNumber: | 2533698654 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E 79TH ST | ||||||||
| Address2: | SUITE 7J | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100210830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127376990 | ||||||||
| FaxNumber: | 2129883103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | 111075 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 111075 | 01 | NY | HIP | OTHER | P518630 | 01 | NY | OXFORD | OTHER | 00198843 | 05 | NY | MEDICAID | 31O281 | 01 | NY | EMPIRE BLUE CROSS BLUE SH | OTHER |