Provider Demographics
NPI:1679801666
Name:REILLY, PETER (RD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 SW 59TH PL APT 110
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5133
Mailing Address - Country:US
Mailing Address - Phone:718-349-3674
Mailing Address - Fax:
Practice Address - Street 1:7500 SW 59TH PL APT 110
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-5133
Practice Address - Country:US
Practice Address - Phone:718-349-3674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered