Provider Demographics
NPI:1063780914
Name:REIDY, GERARD CORNELIUS JR (LAC, MSTOM , CA)
Entity type:Individual
Prefix:MR
First Name:GERARD
Middle Name:CORNELIUS
Last Name:REIDY
Suffix:JR
Gender:M
Credentials:LAC, MSTOM , CA
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Mailing Address - Street 1:505 DOWNER ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-4112
Mailing Address - Country:US
Mailing Address - Phone:908-612-5698
Mailing Address - Fax:
Practice Address - Street 1:111 QUIMBY ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-2185
Practice Address - Country:US
Practice Address - Phone:908-612-5698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJMZ000203171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist