Provider Demographics
NPI:1902083322
Name:REISS, STEPHEN E
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:E
Last Name:REISS
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 1:1829 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2453
Mailing Address - Country:US
Mailing Address - Phone:516-378-7645
Mailing Address - Fax:516-771-4630
Practice Address - Street 1:1829 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2453
Practice Address - Country:US
Practice Address - Phone:516-378-7645
Practice Address - Fax:516-771-4630
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01352670Medicaid