Healthcare Provider Details

I. General information

NPI: 1265628994
Provider Name (Legal Business Name): REYNALDO L DESCALSO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W STRATFORD RD
AVON PARK FL
33825-8091
US

IV. Provider business mailing address

1221 W STRATFORD RD
AVON PARK FL
33825-8091
US

V. Phone/Fax

Practice location:
  • Phone: 863-453-7579
  • Fax: 863-453-8390
Mailing address:
  • Phone: 863-453-7579
  • Fax: 863-453-8390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25032
License Number StateFL

VIII. Authorized Official

Name: DR. REY LUMUCSO DESCALSO
Title or Position: PRESIDENT
Credential: 25032
Phone: 863-453-7579