Provider Demographics
NPI:1639158033
Name:AUSTRIACO, ALFREDO REYES (MD)
Entity Type:Individual
Prefix:
First Name:ALFREDO
Middle Name:REYES
Last Name:AUSTRIACO
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 1:970 E WASHINGTON ST
Mailing Address - Street 2:SUITE #103
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3332
Mailing Address - Country:US
Mailing Address - Phone:330-725-5860
Mailing Address - Fax:330-725-4737
Practice Address - Street 1:970 E WASHINGTON ST
Practice Address - Street 2:SUITE #103
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3332
Practice Address - Country:US
Practice Address - Phone:330-725-5860
Practice Address - Fax:330-725-4737
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034065207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0226259Medicaid
OH0226259Medicaid
OH0373602Medicare ID - Type Unspecified