Provider Demographics
NPI:1356317416
Name:RIESENBERG, DANIEL MARK (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:RIESENBERG
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 1:3269 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-263-4722
Mailing Address - Fax:928-263-4794
Practice Address - Street 1:30037 N WHIPSAW RD
Practice Address - Street 2:101
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-5195
Practice Address - Country:US
Practice Address - Phone:623-238-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4210208800000X
AZ23718208800000X
NV12281208800000X
CAG31678208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP0010CBMedicare UPIN