Healthcare Provider Details

I. General information

NPI: 1164428132
Provider Name (Legal Business Name): ROBERTO REYES RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 CALLE BALDORIOTY
COAMO PR
00769-2412
US

IV. Provider business mailing address

PO BOX 1869
COAMO PR
00769-1869
US

V. Phone/Fax

Practice location:
  • Phone: 787-825-2966
  • Fax: 787-825-6177
Mailing address:
  • Phone: 787-825-2966
  • Fax: 787-825-6177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10318
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: