MEDICARE: JUAN L. RIESTRA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0805X	Geriatric Psychiatry Physician	25MA05785800	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841255320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN L. RIESTRA M.D.

Provider Business Mailing Address
First Line	:	1 RUBINO RD
Second Line	:
City	:	WEST CALDWELL
State	:	NJ
Zip	:	07006-8033
Country	:	US
Telephone Number	:	973-985-1698
Fax Number	:	973-439-5780

Provider Business Practice Location Address
First Line	:	70 PARK ST
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-5907
Country	:	US
Telephone Number	:	973-655-9300
Fax Number	:	973-439-5780

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	08/30/2010

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