Provider Demographics
NPI:1275542482
Name:REILLY, MARY D (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:REILLY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1023 HOPE ST STE 4
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06907-2122
Mailing Address - Country:US
Mailing Address - Phone:203-358-9358
Mailing Address - Fax:203-358-9348
Practice Address - Street 1:1023 HOPE ST STE 4
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06907-2122
Practice Address - Country:US
Practice Address - Phone:203-358-9358
Practice Address - Fax:203-358-9348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000593213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT480000632Medicare UPIN
CTU55908Medicare UPIN
CT5316220001Medicare NSC
CT480000633Medicare UPIN