Provider Demographics
NPI:1538165519
Name:ISSERMAN, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:ISSERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:11433 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7108
Practice Address - Country:US
Practice Address - Phone:314-432-1134
Practice Address - Fax:314-432-1135
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6910207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO180032433OtherRAILROAD MEDICARE
A14078Medicare UPIN
MO008006438Medicare PIN
MOMA5227042Medicare UPIN