Healthcare Provider Details

I. General information

NPI: 1679682249
Provider Name (Legal Business Name): ODIN DELOS REYES D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 POMPERAUG OFFICE PARK SUITE 105
SOUTHBURY CT
06488-2295
US

IV. Provider business mailing address

1 POMPERAUG OFFICE PARK SUITE 105
SOUTHBURY CT
06488-2295
US

V. Phone/Fax

Practice location:
  • Phone: 203-262-6100
  • Fax: 203-264-6679
Mailing address:
  • Phone: 203-262-6100
  • Fax: 203-264-6679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberCT 000 680
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: