Provider Demographics
NPI:1780991547
Name:REYNA, JAVIER (MD)
Entity type:Individual
Prefix:DR
First Name:JAVIER
Middle Name:
Last Name:REYNA
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 1:18300 NW 62ND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-8207
Mailing Address - Country:US
Mailing Address - Phone:305-749-6203
Mailing Address - Fax:786-520-3173
Practice Address - Street 1:18300 NW 62ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-8207
Practice Address - Country:US
Practice Address - Phone:305-749-6203
Practice Address - Fax:786-520-3173
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108112207R00000X
FLME102118207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004485600Medicaid