Provider Demographics
NPI:1982709432
Name:REIS, MARK THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:REIS
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:81 HIGHLAND SPRINGS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-3170
Practice Address - Country:US
Practice Address - Phone:951-845-0313
Practice Address - Fax:360-414-5758
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88836207X00000X
WA00032312207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000258Medicaid
WA8467847Medicaid
CAFU515ZOtherMEDICARE
WA8943021OtherCRIME VICTIMS
WA215163OtherLABOR & IND
WA8467847Medicaid
WA215163OtherLABOR & IND