Provider Demographics
NPI:1093799835
Name:REISS, PAUL I (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:I
Last Name:REISS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 ALBEMARLE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-6617
Mailing Address - Country:US
Mailing Address - Phone:704-568-5444
Mailing Address - Fax:704-568-5445
Practice Address - Street 1:4915 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6617
Practice Address - Country:US
Practice Address - Phone:704-568-5444
Practice Address - Fax:704-568-5445
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908145Medicaid
NC08145OtherBCBS
NC243046Medicare ID - Type UnspecifiedMEDICARE
NCT64018Medicare UPIN