Basic Information
| Provider Information | |||||||||
| NPI: | 1609876341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REISS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10170 SORRENTO VALLEY RD | ||||||||
| Address2: | MAIL DROP SV-5 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587845888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1011 DEVONSHIRE DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920245136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606325456 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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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 | 207RN0300X | G61155 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 00G611550 | 05 | CA | MEDICAID |