Provider Demographics
NPI:1265628994
Name:REYNALDO L DESCALSO MD PA
Entity Type:Organization
Organization Name:REYNALDO L DESCALSO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REY
Authorized Official - Middle Name:LUMUCSO
Authorized Official - Last Name:DESCALSO
Authorized Official - Suffix:
Authorized Official - Credentials:25032
Authorized Official - Phone:863-453-7579
Mailing Address - Street 1:1221 W STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-8091
Mailing Address - Country:US
Mailing Address - Phone:863-453-7579
Mailing Address - Fax:863-453-8390
Practice Address - Street 1:1221 W STRATFORD RD
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-8091
Practice Address - Country:US
Practice Address - Phone:863-453-7579
Practice Address - Fax:863-453-8390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25032208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037572100Medicaid
FLAH876Medicare PIN