Basic Information
| Provider Information | |||||||||
| NPI: | 1710199096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | GONZALO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12740 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926852740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628093527 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 DALLAS ST | ||||||||
| Address2: | ATTN: EMERGENCY ROOM | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782051201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106140180 | ||||||||
| FaxNumber: | 2106157170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N1101 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 196365402 | 05 | TX | MEDICAID | 196365401 | 05 | TX | MEDICAID | 8AH279 | 01 | TX | BCBSTX | OTHER |