Provider Demographics
NPI:1174899819
Name:RIESER, CRYSTAL YVETTE (DO)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:YVETTE
Last Name:RIESER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W231N1440 CORPORATE CT
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1303
Mailing Address - Country:US
Mailing Address - Phone:262-896-6010
Mailing Address - Fax:
Practice Address - Street 1:W231N1440 CORPORATE CT
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1303
Practice Address - Country:US
Practice Address - Phone:262-896-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI61568-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program