Provider Demographics
NPI:1982838538
Name:REID, SERRA V (DAOM, LAC)
Entity Type:Individual
Prefix:DR
First Name:SERRA
Middle Name:V
Last Name:REID
Suffix:
Gender:F
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2512
Mailing Address - Country:US
Mailing Address - Phone:619-584-4321
Mailing Address - Fax:
Practice Address - Street 1:4201 PARK BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2512
Practice Address - Country:US
Practice Address - Phone:619-584-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12963208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice