Healthcare Provider Details

I. General information

NPI: 1215498522
Provider Name (Legal Business Name): BRIGITTE SHEZELLE REINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

583 S CLARIZZ BLVD
BLOOMINGTON IN
47401-5515
US

IV. Provider business mailing address

855 W 6TH ST APT 11
WINSTON SALEM NC
27101-2538
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4460
  • Fax: 812-355-4092
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number01094423A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberMD220351
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10082676
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01094423A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: