Healthcare Provider Details

I. General information

NPI: 1689506073
Provider Name (Legal Business Name): ROY RIESER
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3202 PORTOFINO PT APT O2
COCONUT CREEK FL
33066-1246
US

IV. Provider business mailing address

3202 PORTOFINO PT APT O2
COCONUT CREEK FL
33066-1246
US

V. Phone/Fax

Practice location:
  • Phone: 718-705-2134
  • Fax:
Mailing address:
  • Phone: 718-705-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number135
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: