Basic Information
| Provider Information | |||||||||
| NPI: | 1205829074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | ANDRES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7727812799 | ||||||||
| FaxNumber: | 7727812716 | ||||||||
| Practice Location | |||||||||
| Address1: | 10050 NW INNOVATION WAY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722861550 | ||||||||
| FaxNumber: | 7722210569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 08/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME100755 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | ME100755 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 147LT | 01 | FL | FLORIDA BLUE | OTHER |