Provider Demographics
NPI:1497748909
Name:REISS, JACQUELINE LEVY (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:LEVY
Last Name:REISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:LEVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1570 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5712
Mailing Address - Country:US
Mailing Address - Phone:314-878-0996
Mailing Address - Fax:
Practice Address - Street 1:1570 WOODLAKE DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5712
Practice Address - Country:US
Practice Address - Phone:314-878-0996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR4P58207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG19057Medicare UPIN