Provider Demographics
NPI:1306822614
Name:REISKIND, MARC ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ALAN
Last Name:REISKIND
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:PO BOX 100267
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0267
Mailing Address - Country:US
Mailing Address - Phone:727-327-2600
Mailing Address - Fax:727-327-2644
Practice Address - Street 1:4400 140TH AVE N
Practice Address - Street 2:SUITE 110
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3863
Practice Address - Country:US
Practice Address - Phone:727-327-2600
Practice Address - Fax:727-327-2644
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63914208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004873000Medicaid
FL23074Medicare ID - Type Unspecified
FLF63790Medicare UPIN
FL23074Medicare PIN