1043462104 NPI number — JOSE R. REYNA, JR., M.D., P.A.

Table of content: (NPI 1043462104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043462104 NPI number — JOSE R. REYNA, JR., M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSE R. REYNA, JR., M.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043462104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
435 SAINT MICHAELS DR
Provider Second Line Business Mailing Address:
SUITE A-202
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-7672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-820-2600
Provider Business Mailing Address Fax Number:
505-820-2602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
435 SAINT MICHAELS DR
Provider Second Line Business Practice Location Address:
SUITE A-202
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-7672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-820-2600
Provider Business Practice Location Address Fax Number:
505-820-2602
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
REYNA
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
REYNALDO
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
505-820-2600

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  2001-88 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: E1048 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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