Provider Demographics
NPI:1942267158
Name:REISNER, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:REISNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 JEWETT AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1804
Mailing Address - Country:US
Mailing Address - Phone:201-332-3354
Mailing Address - Fax:201-332-0180
Practice Address - Street 1:196 JEWETT AVENUE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304
Practice Address - Country:US
Practice Address - Phone:201-332-3354
Practice Address - Fax:201-332-0180
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA50929207RG0300X
NJ25MA05092900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3914500Medicaid
574091Medicare ID - Type Unspecified
NJ3914500Medicaid