Provider Demographics
NPI:1841210150
Name:REISKYTL, JOHN RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:REISKYTL
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 1:1205 NORTH AVE
Mailing Address - Street 2:CLEVELAND VA CBOC
Mailing Address - City:CLEVELAND
Mailing Address - State:WI
Mailing Address - Zip Code:53015-1413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 NORTH AVE
Practice Address - Street 2:CLEVELAND VA CBOC
Practice Address - City:CLEVELAND
Practice Address - State:WI
Practice Address - Zip Code:53015-1413
Practice Address - Country:US
Practice Address - Phone:920-693-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE95155Medicare UPIN