Provider Demographics
NPI:1376635458
Name:REILLY, JEANNETTE CA (DPM)
Entity type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:CA
Last Name:REILLY
Suffix:
Gender:F
Credentials:DPM
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Other - Credentials:
Mailing Address - Street 1:76 W JIMMIE LEEDS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9411
Mailing Address - Country:US
Mailing Address - Phone:609-404-1300
Mailing Address - Fax:609-404-1929
Practice Address - Street 1:76 WEST JIMMIE LEEDS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9417
Practice Address - Country:US
Practice Address - Phone:609-404-1300
Practice Address - Fax:609-404-1929
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MD00213100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5524601Medicaid
NJ5524601Medicaid
NJ479086DB8Medicare ID - Type Unspecified