Provider Demographics
NPI:1699410332
Name:REYES HERNANDEZ, DIEGO ARMANDO
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:ARMANDO
Last Name:REYES HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 LAURENS AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-2545
Mailing Address - Country:US
Mailing Address - Phone:626-383-2487
Mailing Address - Fax:
Practice Address - Street 1:2750 E WASHINGTON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1449
Practice Address - Country:US
Practice Address - Phone:626-296-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program