Provider Demographics
NPI:1861503427
Name:REYES, ANTONIO P (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:P
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 1:4239 FARNAM ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2858
Mailing Address - Country:US
Mailing Address - Phone:402-552-2320
Mailing Address - Fax:402-552-2330
Practice Address - Street 1:4239 FARNAM ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2858
Practice Address - Country:US
Practice Address - Phone:402-552-2320
Practice Address - Fax:402-552-2330
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20540207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025652600Medicaid
NEG62746Medicare UPIN
NE060049317Medicare PIN
NE098652006Medicare PIN
NE10025652600Medicaid
IA55794Medicare PIN
NE086309Medicare ID - Type UnspecifiedMEDICARE
IA55702Medicare PIN