Provider Demographics
NPI:1518900315
Name:REALE, DOUGLAS OTTO (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:OTTO
Last Name:REALE
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:PO BOX 198227
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8227
Mailing Address - Country:US
Mailing Address - Phone:786-596-6525
Mailing Address - Fax:786-596-5986
Practice Address - Street 1:8900 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176
Practice Address - Country:US
Practice Address - Phone:786-596-6525
Practice Address - Fax:786-596-5986
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99068207ZP0102X
PAMD423293207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010541520001Medicaid
PA1010541520001Medicaid
PA032534Medicare ID - Type Unspecified