1700844222 NPI number — MR. SOL REISIN MD

Table of content: MR. SOL REISIN MD (NPI 1700844222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700844222 NPI number — MR. SOL REISIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REISIN
Provider First Name:
SOL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700844222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 WEST ATEN ROAD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
IMPERIAL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92251-9805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-355-7730
Provider Business Mailing Address Fax Number:
760-355-7731

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 NORTH IMPERIAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-4242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-353-4710
Provider Business Practice Location Address Fax Number:
760-545-0244
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A39697 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: A39697 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ47484Z . This is a "BLUE SHIELD ZZZ#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0066310 . This is a "GROUP MEDI-CAL #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A396970 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110111657 . This is a "RAILROAD PIN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W13536 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WA39697B . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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