Provider Demographics
NPI:1144224908
Name:REYES, EVANGELINE A (MD)
Entity Type:Individual
Prefix:DR
First Name:EVANGELINE
Middle Name:A
Last Name:REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18111 BROOKHURST STREET
Mailing Address - Street 2:STE. # 6100
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7516
Mailing Address - Country:US
Mailing Address - Phone:714-698-0300
Mailing Address - Fax:714-698-0303
Practice Address - Street 1:260 E. ONTARIO AVENUE
Practice Address - Street 2:STE. # 101
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879
Practice Address - Country:US
Practice Address - Phone:951-371-2411
Practice Address - Fax:951-284-0177
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CAA64361174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A643610Medicaid
CA00A643610Medicaid
CA00A643613Medicare PIN