Provider Demographics
NPI:1619086493
Name:RIESSEN, ERIK REINHARD (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:REINHARD
Last Name:RIESSEN
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-855-2900
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST
Practice Address - Street 2:300
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6767
Practice Address - Country:US
Practice Address - Phone:801-507-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10098207R00000X
UT4791468-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063603Medicare PIN