Provider Demographics
NPI:1629023379
Name:KAVILAVEETTIL, REENA JIJU (MD)
Entity Type:Individual
Prefix:DR
First Name:REENA
Middle Name:JIJU
Last Name:KAVILAVEETTIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:REENA
Other - Middle Name:JIJU
Other - Last Name:KAVILAVEETTIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15267 AMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2155
Mailing Address - Country:US
Mailing Address - Phone:813-972-5414
Mailing Address - Fax:813-972-5413
Practice Address - Street 1:15267 AMBERLY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2155
Practice Address - Country:US
Practice Address - Phone:813-972-5414
Practice Address - Fax:813-972-5413
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9ME00927652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272929600Medicaid
FLU5347ZMedicare PIN
FL272929600Medicaid