Provider Demographics
NPI:1578595468
Name:REILEY, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:REILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 COLBY ST
Mailing Address - Street 2:118
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2059
Mailing Address - Country:US
Mailing Address - Phone:510-845-3856
Mailing Address - Fax:510-845-1936
Practice Address - Street 1:3010 COLBY ST
Practice Address - Street 2:118
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2059
Practice Address - Country:US
Practice Address - Phone:510-845-3856
Practice Address - Fax:510-845-1936
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43696207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Not Answered207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G436960Medicaid
CA00G436960OtherBLUE SHIELD
CAG43696OtherSTATE LICENSE
CAG43696OtherBLUE CROSS
CAG43696OtherBLUE CROSS