Basic Information
| Provider Information | |||||||||
| NPI: | 1972599660 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LOS REYES | ||||||||
| FirstName: | EDUARDO | ||||||||
| MiddleName: | GO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 825 2ND AVE | ||||||||
| Address2: | SUITE C6 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703931912 | ||||||||
| FaxNumber: | 2703931913 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707451000 | ||||||||
| FaxNumber: | 2703931913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 39721 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 39721 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 39721 | KY | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0000X | 39721 | KY | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00318957 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000378694 | 01 | KY | BLUE CROSS | OTHER | 64106065 | 05 | KY | MEDICAID |