Provider Demographics
NPI:1861465254
Name:REYES, ROSENBERG ACOSTA (MD)
Entity Type:Individual
Prefix:
First Name:ROSENBERG
Middle Name:ACOSTA
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 1:320 WEST WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214
Mailing Address - Country:US
Mailing Address - Phone:502-368-2563
Mailing Address - Fax:502-368-2427
Practice Address - Street 1:320 WEST WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214
Practice Address - Country:US
Practice Address - Phone:502-368-2563
Practice Address - Fax:502-368-2427
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY595419196OtherMEDICARE PTAN
000000209925OtherBCBS ANTHEM ID
KY080178783OtherRR MEDICARE PROV. ID
KY1158227OtherPASSPORT PROV. ID
KY000000209925OtherANTHEM PROVIDER ID
KY64004104Medicaid
KY595419196OtherMEDICARE PTAN
KY1158227OtherPASSPORT PROV. ID
KY080178783OtherRR MEDICARE PROV. ID
KY1898201Medicare ID - Type Unspecified