=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962749788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD THOMAS REIS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2013
-----------------------------------------------------
Last Update Date | 01/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21281 BURBANK BLVD
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-676-8404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21281 BURBANK BLVD
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-6607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-676-8404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | G38173
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------