Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | DC20361 | CA |
NPI | 1194745455 |
---|---|
Provider Name | Dr. Mark William Reis |
First Address | San Carlos, CA 94070-5109 |
Second Address | San Carlos, CA 94070-5109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC0203610 | (02) | CA |