Provider Demographics
NPI:1790785137
Name:REISER, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:REISER
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 1:40 BIRDSONG PKWY
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-3068
Mailing Address - Country:US
Mailing Address - Phone:716-574-2672
Mailing Address - Fax:
Practice Address - Street 1:40 BIRDSONG PKWY
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-3068
Practice Address - Country:US
Practice Address - Phone:716-574-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1939752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000525977008OtherBLUE SHIELD OF WESTERN NY
NYCR1939750BOtherWORKERS COMPENSATION
NY02060997Medicaid
P00422403OtherRAILROAD MEDICARE
208616656OtherFIDELIS
NYP00259090OtherRAILROAD MEDICARE
00025112506OtherUNIVERA
5611064OtherINDEPENDENT HEALTH
P00422403OtherRAILROAD MEDICARE
NY02060997Medicaid
000525977008OtherBLUE SHIELD OF WESTERN NY
5611064OtherINDEPENDENT HEALTH
NYRA2130Medicare ID - Type Unspecified