Provider Demographics
NPI:1952453797
Name:REILLY, JOHN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:REILLY
Suffix:
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:P.O. BOX 798
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11571-1839
Mailing Address - Country:US
Mailing Address - Phone:516-705-1353
Mailing Address - Fax:
Practice Address - Street 1:1000 N. VILLAGE AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11571
Practice Address - Country:US
Practice Address - Phone:516-705-1353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178140207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY178140OtherLICENSE
NY178140OtherLICENSE