Provider Demographics
NPI:1457331852
Name:REISS, IAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:M
Last Name:REISS
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 1:2555 PONCE DE LEON BLVD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134
Mailing Address - Country:US
Mailing Address - Phone:305-446-4681
Mailing Address - Fax:
Practice Address - Street 1:8900 NORTH KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176
Practice Address - Country:US
Practice Address - Phone:786-596-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL195042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D59678Medicare UPIN
FL91505XMedicare ID - Type UnspecifiedMEDICARE