Provider Demographics
NPI:1083919419
Name:LEO A. REYES, M.D.,P.C.
Entity Type:Organization
Organization Name:LEO A. REYES, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:A
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-338-5940
Mailing Address - Street 1:1664 S. EASTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-4655
Mailing Address - Country:US
Mailing Address - Phone:815-338-5940
Mailing Address - Fax:815-206-5919
Practice Address - Street 1:1664 S. EASTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-4655
Practice Address - Country:US
Practice Address - Phone:815-338-5940
Practice Address - Fax:815-338-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-16
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.045343208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036045343Medicaid
IL036-045343Medicaid