Provider Demographics
NPI:1780668350
Name:REISERT, JEFFREY THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:REISERT
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:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-733-7222
Mailing Address - Fax:307-739-4828
Practice Address - Street 1:555 E BROADWAY AVE STE 201
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-733-7222
Practice Address - Fax:307-739-4828
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9969207R00000X
WY13203A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY156963500Medicaid
NH30010657Medicaid
NHR583EMedicare ID - Type Unspecified