Provider Demographics
NPI:1083659494
Name:REYNOSO, EDGARDO V (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:V
Last Name:REYNOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10335 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5763
Mailing Address - Country:US
Mailing Address - Phone:262-240-9870
Mailing Address - Fax:262-240-9869
Practice Address - Street 1:308 WILLOW AVE
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3808
Practice Address - Country:US
Practice Address - Phone:201-418-1820
Practice Address - Fax:201-418-1822
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA027463002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0576603Medicaid
NY00498577Medicaid
NJ0576603Medicaid
B17685Medicare UPIN