Provider Demographics
NPI:1649354473
Name:REYES, LUIS (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
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 8500-7211
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:609-815-7810
Mailing Address - Fax:
Practice Address - Street 1:40 FULD ST
Practice Address - Street 2:SUITE 303
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638-5247
Practice Address - Country:US
Practice Address - Phone:609-883-5454
Practice Address - Fax:609-883-2565
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02969200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8517304Medicaid
NJC70959Medicare UPIN
NJ8517304Medicaid