Provider Demographics
NPI:1093724098
Name:REYES, JOHN WILLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIS
Last Name:REYES
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 1:350 BONAR AVE
Mailing Address - Street 2:PATHOLOGY DEPARTMENT
Mailing Address - City:WAYNESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15370-1608
Mailing Address - Country:US
Mailing Address - Phone:724-627-3101
Mailing Address - Fax:
Practice Address - Street 1:350 BONAR AVE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-1608
Practice Address - Country:US
Practice Address - Phone:724-627-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036080L207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAD90513Medicare UPIN
PA165088Medicare ID - Type Unspecified