=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689813693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR LUIS REYNOSO PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2009
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 KAIMALI DR
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-0016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-495-7220
-----------------------------------------------------
Fax | 956-425-7801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 629 KAIMALI DR
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-0016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-425-7800
-----------------------------------------------------
Fax | 956-425-7801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LUIS ALBERTO REYNOSO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 956-425-7800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | K1637
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------