Provider Demographics
NPI:1801964770
Name:REYES, GUILLERMO YSMAEL
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:YSMAEL
Last Name:REYES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4142
Mailing Address - Country:US
Mailing Address - Phone:201-530-0261
Mailing Address - Fax:
Practice Address - Street 1:54 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4018
Practice Address - Country:US
Practice Address - Phone:718-299-5454
Practice Address - Fax:718-299-0770
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01812019156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01812019Medicaid