Provider Demographics
NPI:1962749788
Name:REIS, EDWARD THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
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 1:21281 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6607
Mailing Address - Country:US
Mailing Address - Phone:818-676-8404
Mailing Address - Fax:
Practice Address - Street 1:21281 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6607
Practice Address - Country:US
Practice Address - Phone:818-676-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38173208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics