Provider Demographics
NPI:1689614133
Name:REILLY, JOHN FRANCIS JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FRANCIS
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 1:301 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5167
Mailing Address - Country:US
Mailing Address - Phone:386-231-6000
Mailing Address - Fax:317-705-5047
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-231-6000
Practice Address - Fax:317-705-5047
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94006152085R0001X
FLME1432572085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8971181Medicaid
SC5290539OtherCIGNA
SC1220039OtherUNITED
SC5074302OtherAETNA
SCQ0061WMedicaid
SC30246444OtherSELECT HEALTH MEDICAID LINE
SC80067958OtherSELECT HEALTH
FL1205888OtherWELLCARE
SCP01604823OtherRR MEDICARE
SCQ0061WMedicaid
NC2200826GMedicare PIN
SCSC75125714Medicare PIN