Provider Demographics
NPI:1295749398
Name:REINA, DOMENICK J (MD)
Entity type:Individual
Prefix:
First Name:DOMENICK
Middle Name:J
Last Name:REINA
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 1:4620 N. HABANA AVE.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7107
Mailing Address - Country:US
Mailing Address - Phone:813-875-9362
Mailing Address - Fax:813-876-7055
Practice Address - Street 1:4620 N HABANA AVE
Practice Address - Street 2:STE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7107
Practice Address - Country:US
Practice Address - Phone:813-875-9362
Practice Address - Fax:813-876-7055
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 55628207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059975100Medicaid
FL14833XMedicare UPIN
FLF23676Medicare UPIN
FL059975100Medicaid
290014640Medicare PIN