Provider Demographics
NPI:1770682163
Name:REILLY, WING SUE MARIA
Entity Type:Individual
Prefix:MRS
First Name:WING SUE
Middle Name:MARIA
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:WING SUE
Other - Middle Name:MARIA
Other - Last Name:SHIU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2121 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5100
Mailing Address - Country:US
Mailing Address - Phone:260-426-5431
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003648213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery