Provider Demographics
NPI:1871598698
Name:RISOLI, MELISSA (OD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:RISOLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 GERMANTOWN PIKE
Mailing Address - Street 2:STE 200
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1816
Mailing Address - Country:US
Mailing Address - Phone:610-825-8210
Mailing Address - Fax:610-825-8208
Practice Address - Street 1:1404 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2813
Practice Address - Country:US
Practice Address - Phone:610-853-2001
Practice Address - Fax:610-853-3774
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00568500152W00000X
PAOEG000239152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8316309Medicaid
PA0016038600001Medicaid
PA038523KHGMedicare PIN
NJ8316309Medicaid
PA0016038600001Medicaid