Provider Demographics
NPI:1689611311
Name:REYNAGA, ROSA M (MD)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:M
Last Name:REYNAGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12729 PIONEER BLVD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2873
Mailing Address - Country:US
Mailing Address - Phone:562-207-2270
Mailing Address - Fax:562-207-2279
Practice Address - Street 1:12729 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2873
Practice Address - Country:US
Practice Address - Phone:562-207-2270
Practice Address - Fax:562-207-2279
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53875207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
014067OtherHEALTH NET ID #
CA00G538750Medicaid
00G538750OtherBLUE SHIELD ID #
110195911OtherRAILROAD
CA00G538750Medicaid
00G538750OtherBLUE SHIELD ID #
014067OtherHEALTH NET ID #
110195911OtherRAILROAD