Provider Demographics
NPI:1760550545
Name:REISWIG, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:REISWIG
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 1201
Mailing Address - Street 2:981 SOUTH MARKET BLVD
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0230
Mailing Address - Country:US
Mailing Address - Phone:360-748-4991
Mailing Address - Fax:360-748-7778
Practice Address - Street 1:981 SOUTH MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-0230
Practice Address - Country:US
Practice Address - Phone:360-748-4991
Practice Address - Fax:360-748-7778
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000139932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1016104Medicaid
WA0076572OtherL & I
WA0076572OtherL & I
WA1016104Medicaid
BR0500620OtherDEA