Provider Demographics
NPI:1497947998
Name:RIESEN, MATTHEW C (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:RIESEN
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 1:1132 HAGER ST
Mailing Address - Street 2:#600
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2423
Mailing Address - Country:US
Mailing Address - Phone:419-394-5851
Mailing Address - Fax:419-394-0702
Practice Address - Street 1:1132 HAGER ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2423
Practice Address - Country:US
Practice Address - Phone:419-394-5851
Practice Address - Fax:419-394-0702
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35. 099958208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice