Provider Demographics
NPI:1336135904
Name:REYNOLDS, MARLETA (MD)
Entity Type:Individual
Prefix:
First Name:MARLETA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 118
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-4210
Mailing Address - Fax:312-227-9637
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:800-543-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360620512086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062051Medicaid
WI80837700Medicaid
IL1627123OtherBCBS PROVIDER ID
ILE24553Medicare UPIN