Provider Demographics
NPI:1396794400
Name:REYES, VICENTE EDGARDO SR (MD)
Entity type:Individual
Prefix:DR
First Name:VICENTE
Middle Name:EDGARDO
Last Name:REYES
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:67 OLD CLAIRTON RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-3907
Mailing Address - Country:US
Mailing Address - Phone:412-655-3444
Mailing Address - Fax:412-655-2228
Practice Address - Street 1:2027 LEBANON CHURCH RD FL 2
Practice Address - Street 2:
Practice Address - City:WEST MIFFLIN
Practice Address - State:PA
Practice Address - Zip Code:15122-2461
Practice Address - Country:US
Practice Address - Phone:412-655-3444
Practice Address - Fax:412-655-2228
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA020590E207R00000X
PAMD020590E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00718667Medicaid
PA030216Medicare ID - Type Unspecified
PA00718667Medicaid