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General NPI Number Information
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NPI Number | 1356087860
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Entity Type | Individual
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Provider Name | GUILLERMO RIESTRA
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Gender | Male
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Dates
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Enumeration Date | 05/08/2022
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Last Update Date | 09/02/2024
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Provider Practice Location Address
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Address Line | 240 WILLIAMSON ST
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City | ELIZABETH
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State | NJ
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Zip | 07202-3674
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Country | US
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Telephone | 908-994-5480
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Fax |
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Provider Business Mailing Address
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Address Line | 240 WILLIAMSON ST STE 200
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City | ELIZABETH
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State | NJ
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Zip | 07202-3671
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Country | US
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Telephone | 908-353-1777
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 25MD00381700
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License Number State | NJ
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