Basic Information
| Provider Information | |||||||||
| NPI: | 1982709432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REIS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10069 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093354188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 81 HIGHLAND SPRINGS AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922233170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518450313 | ||||||||
| FaxNumber: | 3604145758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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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 | 207X00000X | G88836 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 00032312 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000258 | 05 | OR | MEDICAID | 8467847 | 05 | WA | MEDICAID | FU515Z | 01 | CA | MEDICARE | OTHER | 8943021 | 01 | WA | CRIME VICTIMS | OTHER | 215163 | 01 | WA | LABOR & IND | OTHER |