Provider Demographics
NPI:1114011186
Name:CIPRIANO M DE LOS REYES JR MD INC
Entity Type:Organization
Organization Name:CIPRIANO M DE LOS REYES JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CIPRIANO
Authorized Official - Middle Name:M
Authorized Official - Last Name:DE LOS REYES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:510-222-2121
Mailing Address - Street 1:2644 APPIAN WAY
Mailing Address - Street 2:#111
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2240
Mailing Address - Country:US
Mailing Address - Phone:510-222-2121
Mailing Address - Fax:510-222-2126
Practice Address - Street 1:2644 APPIAN WAY
Practice Address - Street 2:#111
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2240
Practice Address - Country:US
Practice Address - Phone:510-222-2121
Practice Address - Fax:510-222-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29537207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A295370Medicaid
CA00A295370Medicare ID - Type Unspecified
E33832Medicare UPIN