Provider Demographics
NPI:1932134145
Name:REYES, ADRIAN VILLAFUERTE (MD)
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:VILLAFUERTE
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:PO BOX 11196
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-1196
Mailing Address - Country:US
Mailing Address - Phone:909-799-9115
Mailing Address - Fax:909-799-5636
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1217
Practice Address - Country:US
Practice Address - Phone:909-887-6333
Practice Address - Fax:909-806-1079
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51386207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A51386Medicaid
CA00A51386Medicaid
CAA51386Medicare ID - Type Unspecified
CA00A513860Medicare PIN