Provider Demographics
NPI:1528199858
Name:REYES, JOSE AMODO L
Entity Type:Individual
Prefix:
First Name:JOSE AMODO
Middle Name:L
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5980 W 71ST ST STE 201
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1785
Mailing Address - Country:US
Mailing Address - Phone:317-388-0800
Mailing Address - Fax:317-388-0805
Practice Address - Street 1:5980 W 71ST ST STE 201
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1785
Practice Address - Country:US
Practice Address - Phone:317-388-0800
Practice Address - Fax:317-388-0805
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004391A171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor