Provider Demographics
NPI:1477577583
Name:MARIANO, TEODORO REYES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:TEODORO
Middle Name:REYES
Last Name:MARIANO
Suffix:JR
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 1:800 SPENCERPORT RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-4820
Mailing Address - Country:US
Mailing Address - Phone:585-510-3883
Mailing Address - Fax:
Practice Address - Street 1:800 SPENCERPORT RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-4820
Practice Address - Country:US
Practice Address - Phone:585-510-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129789207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY444111502OtherUNITED HEALTHCARE PPO
NYMD1826OtherPREFERRED CARE PROVIDER
NY80121911498001OtherBCBS OF WESTERN NY
NY5339337OtherAETNA PPO
NYP010129789OtherBLUE CHOICE PROVIDER NO.
NY224911OtherNYS WORKERS COMP
NY2564331OtherAETNA HMO
NY0524OtherBLUE CROSS BLUE SHIELD
NY100768BJOtherPREFERRED CARE PROVIDER
NYMD2826OtherPREFERRED CARE CARDIOLOGY
NY0524OtherBLUE CROSS BLUE SHIELD
NYMD1826OtherPREFERRED CARE PROVIDER
NYC49623Medicare UPIN