Provider Demographics
NPI:1487630851
Name:RIESZ, LAWRENCE ADAM (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ADAM
Last Name:RIESZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12200 NW 77TH MNR
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33076-4511
Mailing Address - Country:US
Mailing Address - Phone:954-346-3482
Mailing Address - Fax:
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:954-355-5519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042718207P00000X
FLME96288207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275748600Medicaid
FLAB226ZMedicare PIN
CTI23917Medicare UPIN
FLAB226YMedicare PIN