Provider Demographics
NPI:1811092596
Name:REYES, THOR-ALCYONE L (MD)
Entity type:Individual
Prefix:
First Name:THOR-ALCYONE
Middle Name:L
Last Name:REYES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5353 TOPANGA CANYON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1737
Mailing Address - Country:US
Mailing Address - Phone:818-704-1579
Mailing Address - Fax:818-704-8790
Practice Address - Street 1:5353 TOPANGA CANYON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1737
Practice Address - Country:US
Practice Address - Phone:818-704-1579
Practice Address - Fax:818-704-8790
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC384082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C384080Medicaid
C38408Medicare ID - Type Unspecified
A89057Medicare UPIN