Provider Demographics
NPI:1699832535
Name:RIETSEMA, WOUTER J (MD)
Entity Type:Individual
Prefix:
First Name:WOUTER
Middle Name:J
Last Name:RIETSEMA
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 2868
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0259
Mailing Address - Country:US
Mailing Address - Phone:518-562-7900
Mailing Address - Fax:518-562-7933
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-561-2000
Practice Address - Fax:518-561-0881
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195737207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000405209002OtherBS OF NENY
NY01561260Medicaid
NY119037OtherMVP
NY7423705OtherAETNA
NY044661958OtherHEALTH NET
NY09004310OtherEMPIRE BC BS
NY141338471OtherGHI
NYP010195737OtherEXCELLUS UTICA WATERTOWN
NY141338471OtherFIDELIS
NY114406OtherVALUE OPTIONS
NY440002865OtherRAILROAD MEDICARE
F67523Medicare UPIN
NY01561260Medicaid