Provider Demographics
NPI:1265420053
Name:REILLY-NIVERS, REBECCA JEAN (DPM)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:JEAN
Last Name:REILLY-NIVERS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12705 RIO BRAVO ST
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-4073
Mailing Address - Country:US
Mailing Address - Phone:832-526-7567
Mailing Address - Fax:
Practice Address - Street 1:12705 RIO BRAVO ST
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-4073
Practice Address - Country:US
Practice Address - Phone:281-369-7064
Practice Address - Fax:281-369-7073
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1618213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0927915-01Medicaid
TXU21035Medicare UPIN
TX0927915-01Medicaid