Provider Demographics
NPI:1295849438
Name:RENO, RICHARD CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHARLES
Last Name:RENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 AIRPORT ROAD
Mailing Address - Street 2:PEDIATRIC DEPARTMENT
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541
Mailing Address - Country:US
Mailing Address - Phone:850-269-6400
Mailing Address - Fax:850-654-9581
Practice Address - Street 1:990 AIRPORT ROAD
Practice Address - Street 2:PEDIATRIC DEPARTMENT
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541
Practice Address - Country:US
Practice Address - Phone:850-269-6400
Practice Address - Fax:850-654-9581
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME79721208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251905900Medicaid
FL58890OtherFLORIDA BLUE
FL251905900Medicaid