Provider Demographics
NPI:1326493198
Name:THOMAS, REENA ELSA
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:ELSA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10405 FLAT BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-5829
Mailing Address - Country:US
Mailing Address - Phone:804-495-5842
Mailing Address - Fax:
Practice Address - Street 1:4745 OGLETOWN STANTON RD STE 116
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:804-495-5842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEC1-0013178208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program