Provider Demographics
NPI:1578666061
Name:REYNOSO, ELSA S (MD)
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:S
Last Name:REYNOSO
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 1:102 11 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:717-898-5200
Mailing Address - Fax:
Practice Address - Street 1:990 WESTBURY ROAD SUITE #100
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5309
Practice Address - Country:US
Practice Address - Phone:516-333-4100
Practice Address - Fax:516-333-4255
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259126208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics