Provider Demographics
NPI:1568666543
Name:REISS, GARY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MICHAEL
Last Name:REISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1520
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073
Mailing Address - Country:US
Mailing Address - Phone:504-349-6423
Mailing Address - Fax:504-349-6062
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE S-450
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-349-6401
Practice Address - Fax:504-349-6444
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200117207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1215040Medicaid
LA1215040Medicaid