Provider Demographics
NPI:1114913423
Name:REISMAN, ELLIOT MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:MICHAEL
Last Name:REISMAN
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 1:4712 N ARMENIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2611
Mailing Address - Country:US
Mailing Address - Phone:813-874-7400
Mailing Address - Fax:813-877-1397
Practice Address - Street 1:4712 N ARMENIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2611
Practice Address - Country:US
Practice Address - Phone:813-874-7400
Practice Address - Fax:813-877-1397
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME577712088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063642800Medicaid
FL11750ZMedicare UPIN
FL063642800Medicaid