Provider Demographics
NPI:1164634309
Name:REID, J PAUL III
Entity Type:Individual
Prefix:
First Name:J
Middle Name:PAUL
Last Name:REID
Suffix:III
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 1:8558 CAMSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-5985
Mailing Address - Country:US
Mailing Address - Phone:904-777-0101
Mailing Address - Fax:
Practice Address - Street 1:8563 ARGYLE BUSINESS LOOP STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-6613
Practice Address - Country:US
Practice Address - Phone:904-777-0101
Practice Address - Fax:904-594-6155
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR86335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4697570001Medicare NSC