Healthcare Provider Details

I. General information

NPI: 1841255320
Provider Name (Legal Business Name): JUAN L. RIESTRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 HAMBURG TPKE STE 1
WAYNE NJ
07470-2132
US

IV. Provider business mailing address

1 RUBINO RD
WEST CALDWELL NJ
07006-8033
US

V. Phone/Fax

Practice location:
  • Phone: 973-389-6020
  • Fax: 973-389-6023
Mailing address:
  • Phone: 973-985-1698
  • Fax: 973-439-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number25MA05785800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: