Provider Demographics
NPI:1710199096
Name:REYES, GONZALO (MD)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:REYES
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:PO BOX 12740
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2740
Mailing Address - Country:US
Mailing Address - Phone:562-809-3527
Mailing Address - Fax:
Practice Address - Street 1:111 DALLAS ST
Practice Address - Street 2:ATTN: EMERGENCY ROOM
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-1201
Practice Address - Country:US
Practice Address - Phone:210-614-0180
Practice Address - Fax:210-615-7170
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1101207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196365402Medicaid
TX196365401Medicaid
TX8AH279OtherBCBSTX
TX196365401Medicaid
TX613418Medicare PIN