Provider Demographics
NPI:1023187424
Name:RELLER, EDWARD CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CRAIG
Last Name:RELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14254 S.R. 574
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527
Mailing Address - Country:US
Mailing Address - Phone:813-349-7700
Mailing Address - Fax:813-349-7761
Practice Address - Street 1:14254 STATE ROAD 574
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527
Practice Address - Country:US
Practice Address - Phone:813-349-7700
Practice Address - Fax:813-340-7761
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85548207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265727900Medicaid
FLB94798Medicare UPIN