Provider Demographics
NPI:1457662256
Name:REID, DERRECE K (MD)
Entity Type:Individual
Prefix:
First Name:DERRECE
Middle Name:K
Last Name:REID
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4939
Mailing Address - Country:US
Mailing Address - Phone:833-774-6333
Mailing Address - Fax:516-433-1036
Practice Address - Street 1:1175 MONTAUK HIGHWAY, SUITE 6
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4939
Practice Address - Country:US
Practice Address - Phone:833-744-6333
Practice Address - Fax:516-433-1036
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT198306207R00000X
NY2799212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine