Provider Demographics
NPI:1578641064
Name:REYES, LILLI ANN GOCO (MD)
Entity Type:Individual
Prefix:
First Name:LILLI ANN
Middle Name:GOCO
Last Name:REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-3429
Mailing Address - Country:US
Mailing Address - Phone:626-405-5951
Mailing Address - Fax:
Practice Address - Street 1:393 E WALNUT ST FL 3
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91188-3429
Practice Address - Country:US
Practice Address - Phone:626-405-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A891981Medicaid
00A891981Medicare ID - Type Unspecified
I27314Medicare UPIN