Basic Information
| Provider Information | |||||||||
| NPI: | 1164916417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERREZUETA REINOSO | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 N CEDAR CREST BLVD STE 411 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181042323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109691917 | ||||||||
| FaxNumber: | 4846647659 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 N FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338014902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632097003 | ||||||||
| FaxNumber: | 8632843083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME147239 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6940524 | 01 | PR | DRIVEN LICENCE | OTHER |