Provider Demographics
NPI:1194917732
Name:REITER, TODD MICHAEL
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:MICHAEL
Last Name:REITER
Suffix:
Gender:M
Credentials:
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-893-3210
Mailing Address - Fax:336-893-3229
Practice Address - Street 1:190 KIMEL PARK DR STE 131
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-718-5763
Practice Address - Fax:336-718-9861
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3777111NR0400X
NC2009-01103208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917822Medicaid
NC5917822Medicaid