Provider Demographics
NPI:1578572210
Name:DE LOS ANGELES, REYNALDO A (MD)
Entity Type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:A
Last Name:DE LOS ANGELES
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 1:409 E 25TH ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-5560
Mailing Address - Country:US
Mailing Address - Phone:308-233-2278
Mailing Address - Fax:
Practice Address - Street 1:409 E 25TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5560
Practice Address - Country:US
Practice Address - Phone:308-233-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2015-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE186362084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEC94838Medicare UPIN
NE268482 DEMedicare ID - Type Unspecified