Basic Information
| Provider Information | |||||||||
| NPI: | 1154394385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REICH | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 95004 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338045004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636807000 | ||||||||
| FaxNumber: | 8636807420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 LAKELAND HILLS BLVD. | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338053019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636807000 | ||||||||
| FaxNumber: | 8662648519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | ME72338 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 254885200 | 05 | FL | MEDICAID |