Provider Demographics
NPI:1700071677
Name:PROTACIO A REYES MD PA
Entity Type:Organization
Organization Name:PROTACIO A REYES MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PROTACIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:301-977-4100
Mailing Address - Street 1:19261 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:SUITE G15
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886
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:SUITE G15
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886
Practice Address - Country:US
Practice Address - Phone:301-977-4100
Practice Address - Fax:301-977-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0004875208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty