Healthcare Provider Details

I. General information

NPI: 1114011186
Provider Name (Legal Business Name): CIPRIANO M DE LOS REYES JR MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 APPIAN WAY #111
PINOLE CA
94564-2240
US

IV. Provider business mailing address

2644 APPIAN WAY #111
PINOLE CA
94564-2240
US

V. Phone/Fax

Practice location:
  • Phone: 510-222-2121
  • Fax: 510-222-2126
Mailing address:
  • Phone: 510-222-2121
  • Fax: 510-222-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA29537
License Number StateCA

VIII. Authorized Official

Name: CIPRIANO M DE LOS REYES JR.
Title or Position: PRESIDENT OWNER
Credential: MD
Phone: 510-222-2121