Provider Demographics
NPI:1588652168
Name:DIAZ-REYES, GUSTAVO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:DIAZ-REYES
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 1:6210 E HWY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:4100 EVERETT DR
Practice Address - Street 2:SUITE 400
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6146
Practice Address - Country:US
Practice Address - Phone:512-295-1333
Practice Address - Fax:512-406-7327
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234797207Y00000X
TXQ9332207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX364332202Medicaid
NY02634339Medicaid
TX364332201Medicaid
TX364332202Medicaid
TX364332201Medicaid
TX538526YKXYMedicare PIN
TX538526YKXVMedicare PIN