Provider Demographics
NPI:1386613321
Name:REISINGER, SUSAN A (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:REISINGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 COLONIAL BLVD.
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:3006 S MARYLAND PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2218
Practice Address - Country:US
Practice Address - Phone:702-894-5100
Practice Address - Fax:702-894-5108
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV85462085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY201561Medicaid
NV2018066Medicaid
NMG1986Medicaid
CAXPY201561Medicaid
E69670Medicare UPIN