Provider Demographics
NPI:1619157385
Name:REYNA, GWENDOLYN G (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:G
Last Name:REYNA
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 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:800-232-3550
Mailing Address - Fax:
Practice Address - Street 1:801 ENCINO PL NE
Practice Address - Street 2:SUITE E-12
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2612
Practice Address - Country:US
Practice Address - Phone:505-842-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-00532083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10231773Medicaid
NM53938577Medicaid
NM46650024Medicaid
NM28777841Medicaid
NM51305879Medicaid
NM01786342Medicaid
NM46650024Medicaid
NMNMB0002Medicare PIN