Provider Demographics
NPI:1164916417
Name:BERREZUETA REINOSO, CHRISTOPHER DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DAVID
Last Name:BERREZUETA REINOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1605 N CEDAR CREST BLVD STE 411
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-2323
Mailing Address - Country:US
Mailing Address - Phone:610-969-1917
Mailing Address - Fax:484-664-7659
Practice Address - Street 1:206 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4902
Practice Address - Country:US
Practice Address - Phone:863-209-7003
Practice Address - Fax:863-284-3083
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME147239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6940524OtherDRIVEN LICENCE