Provider Demographics
NPI:1154461978
Name:REYES, CRISANTO M (MD)
Entity Type:Individual
Prefix:
First Name:CRISANTO
Middle Name:M
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 1:207 N AXTEL AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-1003
Mailing Address - Country:US
Mailing Address - Phone:815-889-4241
Mailing Address - Fax:815-889-4244
Practice Address - Street 1:34 E JONES ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IL
Practice Address - Zip Code:60953-1046
Practice Address - Country:US
Practice Address - Phone:815-889-4241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-078546207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01040271AMedicaid
IN100377000AMedicaid
IL36078546Medicaid
ILK13359Medicare PIN
ILF26832Medicare UPIN
IL825510Medicare ID - Type Unspecified
IL143425Medicare ID - Type UnspecifiedRHC
IN01040271AMedicaid