Provider Demographics
NPI:1497872816
Name:REESE, DONALD J (DPM)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:REESE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NANTICOKE
Mailing Address - State:PA
Mailing Address - Zip Code:18634-2203
Mailing Address - Country:US
Mailing Address - Phone:570-735-1100
Mailing Address - Fax:570-740-1386
Practice Address - Street 1:28 W BROAD ST
Practice Address - Street 2:
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-2203
Practice Address - Country:US
Practice Address - Phone:570-735-1100
Practice Address - Fax:570-740-1386
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-002772 L213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1213309Medicaid
PAT28475Medicare UPIN
PA1213309Medicaid
PA6316270001Medicare NSC