MEDICARE: JACK R REID JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	L018291	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	P00335585	OTHER	LA	RAILROAD MCARE

General Provider Information

NPI Number	:	1518968262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK R REID JR. MD

Provider Business Mailing Address
First Line	:	PO BOX 877
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70727-0877
Country	:	US
Telephone Number	:	225-791-3117
Fax Number	:	225-791-3122

Provider Business Practice Location Address
First Line	:	5000 ODONAVAN BLVD STE 307
Second Line	:
City	:	WALKER
State	:	LA
Zip	:	70785-6355
Country	:	US
Telephone Number	:	225-791-3117
Fax Number	:	225-791-3122

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	05/26/2022

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