Provider Demographics
NPI:1679876585
Name:REYDEL, MISHA M (PT)
Entity type:Individual
Prefix:DR
First Name:MISHA
Middle Name:M
Last Name:REYDEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:EAST JEWETT
Mailing Address - State:NY
Mailing Address - Zip Code:12424-0051
Mailing Address - Country:US
Mailing Address - Phone:646-415-0463
Mailing Address - Fax:
Practice Address - Street 1:333 COLGATE RD.
Practice Address - Street 2:
Practice Address - City:EAST JEWETT
Practice Address - State:NY
Practice Address - Zip Code:12424-0051
Practice Address - Country:US
Practice Address - Phone:646-415-0463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015573-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist