Provider Demographics
NPI:1083654693
Name:REESE, RANDY R (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:R
Last Name:REESE
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 1:2907 KERRY FOREST PKWY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-6825
Mailing Address - Country:US
Mailing Address - Phone:850-668-3380
Mailing Address - Fax:850-668-3226
Practice Address - Street 1:2907 KERRY FOREST PKWY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-6825
Practice Address - Country:US
Practice Address - Phone:850-668-3380
Practice Address - Fax:850-668-3226
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080040384OtherRAIL ROAD
FL077887700Medicaid
FL077887700Medicaid
FL0771280001Medicare NSC
FL32050TMedicare PIN
FLBL159ZMedicare PIN