Basic Information
| Provider Information | |||||||||
| NPI: | 1306835194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REISS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | WALDORF | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614777700 | ||||||||
| FaxNumber: | 5614777707 | ||||||||
| Practice Location | |||||||||
| Address1: | 19615 S STATE RD 7 | ||||||||
| Address2: | SUITE 32 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614777700 | ||||||||
| FaxNumber: | 5614777707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME82185 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 261096500 | 05 | FL | MEDICAID |