Provider Demographics
NPI:1679556740
Name:REALES, JESUS A (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:A
Last Name:REALES
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 1:1005 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4103
Mailing Address - Country:US
Mailing Address - Phone:305-888-8160
Mailing Address - Fax:305-888-8165
Practice Address - Street 1:1005 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4103
Practice Address - Country:US
Practice Address - Phone:305-888-8160
Practice Address - Fax:305-888-8165
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91306208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH86120Medicare UPIN