Provider Demographics
NPI:1841280716
Name:DE RIESE, CORNELIA SELMA (MD, PHD, MBA)
Entity type:Individual
Prefix:DR
First Name:CORNELIA
Middle Name:SELMA
Last Name:DE RIESE
Suffix:
Gender:F
Credentials:MD, PHD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W 5TH ST # 3212
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-703-5000
Mailing Address - Fax:432-335-5240
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-335-2222
Practice Address - Fax:432-335-1009
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6348207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111572100Medicaid
TX111572101OtherFIRSTCARE COMMERCIAL
NMA117OtherTRIWEST
TX103816802Medicaid
TX103816803Medicaid
NM84497Medicaid
NM000K5175Medicaid
TX83G037OtherBC/BS
NM84497OtherPRESBYTERIAN COMMERCIAL
OK100048670AMedicaid
TX80833ZOtherHMO BLUE
NM000K5175Medicaid
NM84497OtherPRESBYTERIAN COMMERCIAL
TXG35172Medicare UPIN