Basic Information
| Provider Information | |||||||||
| NPI: | 1861478240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE RIESE | ||||||||
| FirstName: | WERNER | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST STOP 7260 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794303300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067431810 | ||||||||
| FaxNumber: | 8067431335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | L4905 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208800000X | L4905 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 111573100 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 111573102 | 05 | TX | MEDICAID | S8149 | 05 | NM | MEDICAID | 104999102 | 05 | TX | MEDICAID | 87183G | 01 | TX | BC/BS | OTHER | A022 | 01 | NM | TRIWEST | OTHER | 104999101 | 05 | TX | MEDICAID | 201021500 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 201021500 | 05 | NM | MEDICAID | 82844Z | 01 | TX | HMO BLUE | OTHER | 100048660B | 05 | OK | MEDICAID |