Provider Demographics
NPI:1063402741
Name:REYNOSO, LUIS A (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:REYNOSO
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 1:2401 N ED CAREY DR
Mailing Address - Street 2:STE C
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8205
Mailing Address - Country:US
Mailing Address - Phone:956-425-7800
Mailing Address - Fax:956-425-7801
Practice Address - Street 1:2401 N ED CAREY DR
Practice Address - Street 2:STE C
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8205
Practice Address - Country:US
Practice Address - Phone:956-425-7800
Practice Address - Fax:956-425-7801
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101347602Medicaid
TXOA3434Medicare UPIN
TX101347602Medicaid