Provider Demographics
NPI:1114037330
Name:YESKE, REGINALD WOODROW
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:WOODROW
Last Name:YESKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 N STUDEBAKER RD STE H
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-4968
Mailing Address - Country:US
Mailing Address - Phone:562-597-9402
Mailing Address - Fax:562-498-5802
Practice Address - Street 1:1190 N STUDEBAKER RD STE H
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-4968
Practice Address - Country:US
Practice Address - Phone:562-597-9402
Practice Address - Fax:562-498-5802
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABY8095538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A84494Medicare UPIN
A33621Medicare ID - Type Unspecified