Provider Demographics
NPI:1891946786
Name:DR CARLOS REYES-PESCADOR
Entity Type:Organization
Organization Name:DR CARLOS REYES-PESCADOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES-PESCADOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-279-1700
Mailing Address - Street 1:1800 N GALLOWAY AVE
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2299
Mailing Address - Country:US
Mailing Address - Phone:972-279-1700
Mailing Address - Fax:971-279-1102
Practice Address - Street 1:1000 ENGLISH RD
Practice Address - Street 2:BLUE BONNET ESTATES
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-8288
Practice Address - Country:US
Practice Address - Phone:972-524-5617
Practice Address - Fax:972-524-1035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARLOS REYES-PESCADOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4693208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031940201Medicaid