Provider Demographics
NPI:1629252457
Name:GOROZA, EDMUND REYES (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:REYES
Last Name:GOROZA
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 1:12273 CATANZARO AVE APT A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-4625
Mailing Address - Country:US
Mailing Address - Phone:718-866-8204
Mailing Address - Fax:
Practice Address - Street 1:10105 BANBURRY CROSS DR STE 170
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144
Practice Address - Country:US
Practice Address - Phone:702-765-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244278-12080P0203X
NJ25MA082730002080P0203X
NV14909208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty