Provider Demographics
NPI:1427052869
Name:REISS, MARTIN BERNARD (DO)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:BERNARD
Last Name:REISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 N 40TH ST
Mailing Address - Street 2:STE 104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2143
Mailing Address - Country:US
Mailing Address - Phone:602-955-8055
Mailing Address - Fax:602-955-6865
Practice Address - Street 1:5110 N 40TH ST
Practice Address - Street 2:STE 104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2143
Practice Address - Country:US
Practice Address - Phone:602-955-8055
Practice Address - Fax:602-955-6865
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12732084P0800X
NY8947002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E20677Medicare UPIN