Healthcare Provider Details

I. General information

NPI: 1508093154
Provider Name (Legal Business Name): REYNALDO PEZZOTTI SMITH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 07/21/2022
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CIUDAD JARDIN 1, #117 ANTHURIUM ST. TOA ALTA,P.R.
TOA ALTA PR
00953-4844
US

IV. Provider business mailing address

156 SUREA HACIENDA SAN JOSE
CAGUAS PR
00725
US

V. Phone/Fax

Practice location:
  • Phone: 787-646-5905
  • Fax:
Mailing address:
  • Phone: 787-420-4054
  • Fax: 787-961-9447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number17615
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1037
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: