Basic Information
| Provider Information | |||||||||
| NPI: | 1639156177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REITTER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 BENEDICTA AVE | ||||||||
| Address2: | |||||||||
| City: | TRINIDAD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810822005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7198469213 | ||||||||
| FaxNumber: | 7198462752 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 BENEDICTA AVE | ||||||||
| Address2: | |||||||||
| City: | TRINIDAD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810822005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7198469213 | ||||||||
| FaxNumber: | 7198462752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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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 | 208600000X | DR.50480 | CO | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 44809 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 091094500 | 05 | MN | MEDICAID |