Provider Demographics
NPI:1619959509
Name:REAGLE, ROBERT R (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:REAGLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 365
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5403
Mailing Address - Country:US
Mailing Address - Phone:248-922-9283
Mailing Address - Fax:248-922-9286
Practice Address - Street 1:5701 BOW POINTE DR STE 365
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-922-9283
Practice Address - Fax:248-922-9286
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRR007791207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2884513Medicaid
MI2884513Medicaid
0F36374004Medicare ID - Type Unspecified