Basic Information
| Provider Information | |||||||||
| NPI: | 1679776959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RISDEN | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9101 LBJ FWY | ||||||||
| Address2: | SUITE 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752432057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727925700 | ||||||||
| FaxNumber: | 2143497707 | ||||||||
| Practice Location | |||||||||
| Address1: | 399 W CAMPBELL RD | ||||||||
| Address2: | MEDICAL PLAZA II, SUITE 410 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750803595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722387799 | ||||||||
| FaxNumber: | 9722387135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | M5492 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 8BJ292 | 01 | TX | BCBS | OTHER | 189247301 | 05 | TX | MEDICAID | 189247304 | 05 | TX | MEDICAID | 189247306 | 05 | TX | MEDICAID | 613337 | 01 | TX | MEDICARE PTAN | OTHER | 189247307 | 05 | TX | MEDICAID | 189247302 | 05 | TX | MEDICAID | 189247303 | 05 | TX | MEDICAID |