Provider Demographics
NPI:1891874244
Name:DELOS REYES, ENRIQUE R (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:R
Last Name:DELOS REYES
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3807
Mailing Address - Country:US
Mailing Address - Phone:516-889-7515
Mailing Address - Fax:516-889-7515
Practice Address - Street 1:124 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3807
Practice Address - Country:US
Practice Address - Phone:516-889-7515
Practice Address - Fax:516-889-7515
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04389-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00549495Medicaid
C57041Medicare UPIN
NY00549495Medicaid