Healthcare Provider Details

I. General information

NPI: 1295704427
Provider Name (Legal Business Name): JOHN DAVID REISMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GREENBUSH ST
LAFAYETTE IN
47904-2479
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-448-7619
Mailing address:
  • Phone: 877-668-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01040939A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: