Provider Demographics
NPI:1083774475
Name:REYES, JUAN D (MD)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:D
Last Name:REYES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:72 DARTMOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-429-4518
Mailing Address - Fax:718-575-4197
Practice Address - Street 1:91 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-963-2215
Practice Address - Fax:718-575-4197
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102459208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00177211Medicaid
512621Medicare ID - Type Unspecified
NY00177211Medicaid