Provider Demographics
NPI:1306926142
Name:REISSER, PAUL C (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:REISSER
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 1:2100 LYNN RD
Mailing Address - Street 2:STE 215
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8038
Mailing Address - Country:US
Mailing Address - Phone:805-497-4974
Mailing Address - Fax:805-496-7636
Practice Address - Street 1:2100 LYNN RD STE 215
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8038
Practice Address - Country:US
Practice Address - Phone:805-497-4974
Practice Address - Fax:805-496-7636
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW591OtherMEDICARE GROUP
CAW591OtherMEDICARE GROUP
CAW591OtherMEDICARE GROUP