Provider Demographics
NPI:1609834936
Name:RIESENMAN, JOHN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:RIESENMAN
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 1:255 TERRACINA BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4870
Mailing Address - Country:US
Mailing Address - Phone:909-798-1763
Mailing Address - Fax:909-307-6405
Practice Address - Street 1:255 TERRACINA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-798-1763
Practice Address - Fax:909-307-6405
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG479182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A50860Medicare UPIN
OOG479180Medicare ID - Type Unspecified