Basic Information
| Provider Information | |||||||||
| NPI: | 1699774331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIESTER | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 GREENS DAIRY RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276164612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192563576 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 262 LEROY GEORGE DR | ||||||||
| Address2: | STE X | ||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287217430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284528346 | ||||||||
| FaxNumber: | 8284528338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 9800678 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 174400000X | 9800678 | NC | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 891184G | 05 | NC | MEDICAID | BR5074959 | 01 | NC | DEA | OTHER |