Provider Demographics
NPI:1669877908
Name:REYNOSO, CLARISSA VITALINA (MD)
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:VITALINA
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:V
Other - Last Name:REYNOSO AZURIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-8013
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:8415 GOODWOOD BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7851
Practice Address - Country:US
Practice Address - Phone:225-765-8013
Practice Address - Fax:225-765-2033
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA334001208000000X
SCMD41082208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty