=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508907346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIO E REYES MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 04/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10300 SW 72 AVE SUITE 311
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-3015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-898-5340
-----------------------------------------------------
Fax | 305-279-6805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19832 NW 88TH AVE
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33018-6206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-816-5956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIO E REYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-816-5956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------