Healthcare Provider Details

I. General information

NPI: 1063513018
Provider Name (Legal Business Name): WESLEY BETH REISS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 W NECK RD
HUNTINGTON NY
11743-2619
US

IV. Provider business mailing address

191 N OAK ST
N MASSAPEQUA NY
11758-3046
US

V. Phone/Fax

Practice location:
  • Phone: 631-425-6180
  • Fax:
Mailing address:
  • Phone: 631-425-6180
  • Fax: 516-797-7370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number159835
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: