Provider Demographics
NPI:1639190275
Name:REYNOSA, MANUEL J (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:J
Last Name:REYNOSA
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 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:#440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-440-3131
Mailing Address - Fax:310-471-3958
Practice Address - Street 1:147 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2809
Practice Address - Country:US
Practice Address - Phone:805-652-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76600207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13390Medicare PIN
CAW13390BMedicare PIN
CAWG76600EMedicare PIN
CAW13390CMedicare PIN
CAWG76600CMedicare PIN
CAWG76600DMedicare PIN
CAW13390AMedicare PIN
CAWG76600BMedicare PIN