Basic Information
| Provider Information | |||||||||
| NPI: | 1356317416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIESENBERG | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3269 N STOCKTON HILL RD | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864093619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282634722 | ||||||||
| FaxNumber: | 9282634794 | ||||||||
| Practice Location | |||||||||
| Address1: | 30037 N WHIPSAW RD | ||||||||
| Address2: | 101 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853835195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232388890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | K4210 | TX | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 23718 | AZ | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | 12281 | NV | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | G31678 | CA | N | Allopathic & Osteopathic Physicians | Urology |
No ID Information.