Provider Demographics
NPI:1932366143
Name:REISENAUER, JUSTIN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JOSEPH
Last Name:REISENAUER
Suffix:
Gender:M
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-333-1000
Mailing Address - Fax:
Practice Address - Street 1:300 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4439
Practice Address - Country:US
Practice Address - Phone:701-323-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11810207P00000X
MI4301092012207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16048Medicaid
ND16048Medicaid