Provider Demographics
NPI:1700992229
Name:DESCALSO, REYNALDO L (MD)
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:L
Last Name:DESCALSO
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 1:4143 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2131
Mailing Address - Country:US
Mailing Address - Phone:863-386-6480
Mailing Address - Fax:863-386-6497
Practice Address - Street 1:4143 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-2131
Practice Address - Country:US
Practice Address - Phone:863-386-6480
Practice Address - Fax:863-386-6497
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25032208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037572100Medicaid
FL037572100Medicaid
D53475Medicare UPIN