Healthcare Provider Details

I. General information

NPI: 1265871230
Provider Name (Legal Business Name): THOMAS WALTER REEDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2013
Last Update Date: 06/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 WENTWORTH DR
JAMUL CA
91935-1531
US

IV. Provider business mailing address

3355 WENTWORTH DR
JAMUL CA
91935-1531
US

V. Phone/Fax

Practice location:
  • Phone: 619-749-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberGFE19644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: