Healthcare Provider Details

I. General information

NPI: 1346292950
Provider Name (Legal Business Name): JEFFREY G RERES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6042 N 10TH PL
PHOENIX AZ
85014-1929
US

IV. Provider business mailing address

6042 N 10TH PL
PHOENIX AZ
85014-1929
US

V. Phone/Fax

Practice location:
  • Phone: 602-466-2943
  • Fax: 602-466-2943
Mailing address:
  • Phone: 602-466-2943
  • Fax: 602-466-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4459
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: