Provider Demographics
NPI:1912284621
Name:REEN, SANDEEP (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:
First Name:SANDEEP
Middle Name:
Last Name:REEN
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 N NORMA ST STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-6536
Mailing Address - Country:US
Mailing Address - Phone:760-463-1613
Mailing Address - Fax:760-463-1614
Practice Address - Street 1:1525 N NORMA ST STE B
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-6536
Practice Address - Country:US
Practice Address - Phone:760-463-1613
Practice Address - Fax:760-463-1614
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GG163YOtherMEDICARE PTAN