Provider Demographics
NPI:1861448557
Name:REYES, REGINO IRWIN BARISO (PT)
Entity Type:Individual
Prefix:MR
First Name:REGINO IRWIN
Middle Name:BARISO
Last Name:REYES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3787 PALM VALLEY RD
Mailing Address - Street 2:SUITE 102-335
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4183
Mailing Address - Country:US
Mailing Address - Phone:732-495-4501
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTHPARK BLVD
Practice Address - Street 2:STE 408-B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5189
Practice Address - Country:US
Practice Address - Phone:904-429-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0007862225100000X
NJ40QA00648200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0PV9OtherBCBS / FLORIDA BLUE
FLIB888ZMedicare PIN