Provider Demographics
NPI:1700900461
Name:WILBUR R. RESCHLY, M.D., P.A.
Entity Type:Organization
Organization Name:WILBUR R. RESCHLY, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:R
Authorized Official - Last Name:RESCHLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-644-6415
Mailing Address - Street 1:4316 HIGHLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1647
Mailing Address - Country:US
Mailing Address - Phone:863-644-6415
Mailing Address - Fax:863-709-8345
Practice Address - Street 1:4316 HIGHLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1647
Practice Address - Country:US
Practice Address - Phone:863-644-6415
Practice Address - Fax:863-709-8345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24895207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53473Medicare ID - Type Unspecified
FLD56538Medicare UPIN