Provider Demographics
NPI:1063469633
Name:TOLENTINO, REYNALDO T (MD)
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:T
Last Name:TOLENTINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 COLLEGE DR STE 55
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-3128
Mailing Address - Country:US
Mailing Address - Phone:940-552-6800
Mailing Address - Fax:940-552-6802
Practice Address - Street 1:4301 COLLEGE DR RM 500
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-3127
Practice Address - Country:US
Practice Address - Phone:940-552-6800
Practice Address - Fax:940-552-6802
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7794208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034797301Medicaid
TX034797301Medicaid
B27020Medicare UPIN