Provider Demographics
NPI:1649404013
Name:REYES GRAJALES, ERIC W (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
Last Name:REYES GRAJALES
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:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9680
Mailing Address - Fax:239-343-9685
Practice Address - Street 1:2780 CLEVELAND AVE
Practice Address - Street 2:SUITE 809
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5817
Practice Address - Country:US
Practice Address - Phone:239-343-9680
Practice Address - Fax:239-343-9685
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261370207R00000X, 207RI0200X
FLME126359207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016863400Medicaid