Provider Demographics
NPI:1962688283
Name:REISBORD, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:REISBORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12115 MAGNOLIA BLVD
Mailing Address - Street 2:254
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2609
Mailing Address - Country:US
Mailing Address - Phone:323-788-6114
Mailing Address - Fax:
Practice Address - Street 1:12115 MAGNOLIA BLVD
Practice Address - Street 2:254
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-2609
Practice Address - Country:US
Practice Address - Phone:323-788-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG8913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA58727Medicare UPIN