Provider Demographics
NPI:1013412717
Name:REISDORF, CARLI RENSKE (MD)
Entity type:Individual
Prefix:
First Name:CARLI
Middle Name:RENSKE
Last Name:REISDORF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLI
Other - Middle Name:RENSKE
Other - Last Name:HAASBROEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 BON AIR RD
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6919
Practice Address - Country:US
Practice Address - Phone:415-600-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD18657207P00000X, 207PP0204X
CAA166617207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine