Provider Demographics
NPI:1760694525
Name:REISH, ALEX G (DO)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:G
Last Name:REISH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 BASELINE RD., E-104, #274
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303
Mailing Address - Country:US
Mailing Address - Phone:303-225-6625
Mailing Address - Fax:
Practice Address - Street 1:5377 MANHATTAN CIR STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-4345
Practice Address - Country:US
Practice Address - Phone:303-225-6625
Practice Address - Fax:303-225-6626
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO46517207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62451383Medicaid
CO62451383Medicaid