Provider Demographics
NPI:1841461936
Name:ODIN DE LOS REYES DPM INC
Entity type:Organization
Organization Name:ODIN DE LOS REYES DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ODIN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DE LOS REYES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-229-1999
Mailing Address - Street 1:1 POMPERAUG OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2295
Mailing Address - Country:US
Mailing Address - Phone:203-262-6100
Mailing Address - Fax:
Practice Address - Street 1:81 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-4221
Practice Address - Country:US
Practice Address - Phone:860-229-1999
Practice Address - Fax:860-225-8155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 000 680213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4825690001Medicare NSC
CTU70499Medicare UPIN