Provider Demographics
NPI:1700844222
Name:REISIN, SOL (MD)
Entity Type:Individual
Prefix:MR
First Name:SOL
Middle Name:
Last Name:REISIN
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 1:516 WEST ATEN ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:1550 NORTH IMPERIAL AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4242
Practice Address - Country:US
Practice Address - Phone:760-353-4710
Practice Address - Fax:760-545-0244
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39697207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ47484ZOtherBLUE SHIELD ZZZ#
CAGR0066310OtherGROUP MEDI-CAL #
CA00A396970Medicaid
CA110111657OtherRAILROAD PIN#
CAW13536OtherMEDICARE GROUP #
CAWA39697BOtherMEDICARE PTAN
CA110111657OtherRAILROAD PIN#
CAWA39697BOtherMEDICARE PTAN
CAWA39697BMedicare PIN