Provider Demographics
NPI:1922071539
Name:REODICA, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:REODICA
Suffix:
Gender:F
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:901 CAMPUS DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4930
Practice Address - Country:US
Practice Address - Phone:415-642-0707
Practice Address - Fax:650-775-8638
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89673207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFU656XMedicare PIN
CAFU656UMedicare PIN
CAFU656ZMedicare PIN
CAP01163530Medicare PIN
FU656AMedicare PIN
CAFU656TMedicare PIN
CARES000Medicare UPIN
CAFU656WMedicare PIN
CAFU656VMedicare PIN
CAFU656YMedicare PIN
CAP01063983Medicare PIN