Provider Demographics
NPI:1922305929
Name:REISDORF, CHARLES HOWARD (RN, CDE)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HOWARD
Last Name:REISDORF
Suffix:
Gender:M
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:744 W MICHIGAN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1900
Mailing Address - Country:US
Mailing Address - Phone:517-817-7618
Mailing Address - Fax:517-817-7611
Practice Address - Street 1:744 W MICHIGAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1900
Practice Address - Country:US
Practice Address - Phone:517-817-7618
Practice Address - Fax:517-817-7611
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
21310526174H00000X
MI4704278150163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No174H00000XOther Service ProvidersHealth Educator
No163W00000XNursing Service ProvidersRegistered Nurse