1780680520 NPI number — MARTIN T REILLY DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780680520 NPI number — MARTIN T REILLY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REILLY
Provider First Name:
MARTIN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REILLY
Provider Other First Name:
M
Provider Other Middle Name:
TODD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1780680520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/17/2006
NPI Reactivation Date:
03/23/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT 960315
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73196-0315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-548-1367
Provider Business Mailing Address Fax Number:
580-548-1583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 E OKLAHOMA AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73701-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-242-5700
Provider Business Practice Location Address Fax Number:
580-242-5712
Provider Enumeration Date:
06/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  4135 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0114X , with the licence number: 4135 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 4135 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200025140A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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