Provider Demographics
NPI:1205050630
Name:ODIN DE LOS REYES DPM INC
Entity type:Organization
Organization Name:ODIN DE LOS REYES DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:ODIN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DE LOS REYES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-262-6100
Mailing Address - Street 1:1 POMPERAUG OFFICE PARK
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2295
Mailing Address - Country:US
Mailing Address - Phone:230-262-6100
Mailing Address - Fax:203-264-6679
Practice Address - Street 1:1 POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 105
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2295
Practice Address - Country:US
Practice Address - Phone:230-262-6100
Practice Address - Fax:203-264-6679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000680213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004186947Medicaid
CT004186947Medicaid
CT4825690001Medicare NSC