Healthcare Provider Details

I. General information

NPI: 1669877908
Provider Name (Legal Business Name): CLARISSA VITALINA REYNOSO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLARISSA V REYNOSO AZURIS MD

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 GOODWOOD BLVD STE 202
BATON ROUGE LA
70806-7851
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-8013
  • Fax: 225-765-2033
Mailing address:
  • Phone: 225-765-8013
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number334001
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD41082
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: