Provider Demographics
NPI:1679682249
Name:DELOS REYES, ODIN (DPM)
Entity Type:Individual
Prefix:
First Name:ODIN
Middle Name:
Last Name:DELOS REYES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 POMPERAUG OFFICE PARK
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2295
Mailing Address - Country:US
Mailing Address - Phone:203-262-6100
Mailing Address - Fax:203-264-6679
Practice Address - Street 1:1 POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 105
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2295
Practice Address - Country:US
Practice Address - Phone:203-262-6100
Practice Address - Fax:203-264-6679
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 000 680213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT480026445OtherRAILROAD MEDICARE PIN
CT004186947Medicaid
CT480026445OtherRAILROAD MEDICARE PIN
CT4825690001Medicare NSC
CT004186947Medicaid