Provider Demographics
NPI:1720147994
Name:REYES, MARIA MENDOZA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:MENDOZA
Last Name:REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIAGENALYN
Other - Middle Name:MENDOZA
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:461 WALNUT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:KY
Mailing Address - Zip Code:40311-9233
Mailing Address - Country:US
Mailing Address - Phone:859-749-7178
Mailing Address - Fax:
Practice Address - Street 1:1001 CHERRY BLOSSOM WAY
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9564
Practice Address - Country:US
Practice Address - Phone:502-868-4961
Practice Address - Fax:502-868-4998
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33484207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYG65416Medicare UPIN
KY1705101Medicare ID - Type Unspecified