Provider Demographics
NPI:1376538751
Name:REYES, PROTACIO AZARCON (MD)
Entity type:Individual
Prefix:
First Name:PROTACIO
Middle Name:AZARCON
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 1:19261 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:STE G-13
Mailing Address - City:MONTGOMRY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-5026
Mailing Address - Country:US
Mailing Address - Phone:301-977-4100
Mailing Address - Fax:301-977-4101
Practice Address - Street 1:19261 MONTGOMERY VILLAGE AVE
Practice Address - Street 2:STE G-13
Practice Address - City:MONTGOMRY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-5026
Practice Address - Country:US
Practice Address - Phone:301-977-4100
Practice Address - Fax:301-977-4101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0004875208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics