Healthcare Provider Details

I. General information

NPI: 1356317416
Provider Name (Legal Business Name): DANIEL MARK RIESENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30037 N WHIPSAW RD 101
PEORIA AZ
85383-5195
US

IV. Provider business mailing address

3269 N STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

V. Phone/Fax

Practice location:
  • Phone: 623-238-8890
  • Fax:
Mailing address:
  • Phone: 928-263-4722
  • Fax: 928-263-4794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberK4210
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number23718
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number12281
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG31678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: