Healthcare Provider Details

I. General information

NPI: 1326365065
Provider Name (Legal Business Name): GERALD REIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST ROOM 2-281M
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

3501 JOHNSON ST ROOM 2-281M
HOLLYWOOD FL
33021-5421
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-2333
  • Fax:
Mailing address:
  • Phone: 954-265-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberME122778
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: