Provider Demographics
NPI:1225239908
Name:KURIACOSE, REENA (MD)
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:
Last Name:KURIACOSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REENA
Other - Middle Name:
Other - Last Name:PANICKAVEETIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-1000
Mailing Address - Fax:336-718-1052
Practice Address - Street 1:4010 AERIAL WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-9757
Practice Address - Country:US
Practice Address - Phone:541-687-6349
Practice Address - Fax:541-242-8361
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD207R00000X
NC2015-00216207R00000X
ORMD183553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000601Medicare PIN