Provider Demographics
NPI:1841255320
Name:RIESTRA, JUAN L (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:L
Last Name:RIESTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 RUBINO RD
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-8033
Mailing Address - Country:US
Mailing Address - Phone:973-985-1698
Mailing Address - Fax:973-439-5780
Practice Address - Street 1:70 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-5907
Practice Address - Country:US
Practice Address - Phone:973-655-9300
Practice Address - Fax:973-439-5780
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA057858002084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7886802Medicaid
NJ020001Medicare ID - Type UnspecifiedNJ MEDICARE PROVIDER ID #
NJ184729YA79Medicare PIN
NJ7886802Medicaid