Healthcare Provider Details

I. General information

NPI: 1912071663
Provider Name (Legal Business Name): BIBIANA JIN-WAN REISER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 10/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 SAN PABLO ST SUITE 4000
LOS ANGELES CA
90033-4668
US

IV. Provider business mailing address

1450 SAN PABLO ST SUITE 3700
LOS ANGELES CA
90033-4668
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-6335
  • Fax: 323-442-7166
Mailing address:
  • Phone: 323-442-7152
  • Fax: 323-442-7166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA81507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: