Provider Demographics
NPI:1174592521
Name:REYES, EMMANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4036
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-0436
Mailing Address - Country:US
Mailing Address - Phone:973-594-8444
Mailing Address - Fax:973-773-4491
Practice Address - Street 1:110 CLIFTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-1426
Practice Address - Country:US
Practice Address - Phone:973-594-8444
Practice Address - Fax:973-773-4491
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7464703Medicaid
NJ7464703Medicaid
NJG48013Medicare UPIN