Provider Demographics
NPI:1629054796
Name:REILLY, JAMES J JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:REILLY
Suffix:JR
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 1:21 E 87TH ST
Mailing Address - Street 2:APT. 9A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-0506
Mailing Address - Country:US
Mailing Address - Phone:212-426-3781
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2057
Practice Address - Country:US
Practice Address - Phone:718-245-4146
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192665208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0683042Medicaid
NYRE143037Medicare ID - Type Unspecified
NY0683042Medicaid