=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841280716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORNELIA SELMA DE RIESE MD, PHD, MBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2005
-----------------------------------------------------
Last Update Date | 04/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 W 5TH ST
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79763-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-335-2222
-----------------------------------------------------
Fax | 432-335-1009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 W 5TH ST # 3212
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79763-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-703-5000
-----------------------------------------------------
Fax | 432-335-5240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | L6348
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VF0040X
-----------------------------------------------------
Taxonomy Name | Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
-----------------------------------------------------
License Number | L6348
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------