Basic Information
| Provider Information | |||||||||
| NPI: | 1477566875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE-LLACER | ||||||||
| FirstName: | REYNALDO | ||||||||
| MiddleName: | LABITAG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8600 SNOWDEN RIVER PKWY | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210451982 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 CATON AVE | ||||||||
| Address2: | DEPARTMENT OF MEDICINE | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212295201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103686000 | ||||||||
| FaxNumber: | 4103683599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/30/2012 | ||||||||
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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 | 207R00000X | D0061829 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 406470400 | 05 | MD | MEDICAID | 122122 | 01 | JHHC | OTHER | 270887. | 01 | AMERIGROUP | OTHER | 1503644 | 01 | AETNA HMO | OTHER | 0041 | 01 | CAREFIRST | OTHER | 64241604 | 01 | CAREFIRST | OTHER | 7832636 | 01 | AETNA PPO | OTHER |