Provider Demographics
NPI:1033163902
Name:REILLY, JO MARIE R (MD)
Entity Type:Individual
Prefix:
First Name:JO MARIE
Middle Name:R
Last Name:REILLY
Suffix:
Gender:F
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:213-744-0801
Mailing Address - Fax:213-741-1423
Practice Address - Street 1:1400 S GRAND AVE
Practice Address - Street 2:STE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3048
Practice Address - Country:US
Practice Address - Phone:213-744-0801
Practice Address - Fax:213-741-1423
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAA051016207Q00000X
CAA51016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A510160Medicaid
GAP00197281OtherMEDICARE RAILROAD
CA00A510160OtherBLUE SHIELD
CA00A510160OtherBLUE SHIELD
CAWA51016AMedicare PIN