Provider Demographics
NPI:1104810399
Name:REYES, LEOVIGILDO J (MD)
Entity type:Individual
Prefix:DR
First Name:LEOVIGILDO
Middle Name:J
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 1:4401 N ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3917
Mailing Address - Country:US
Mailing Address - Phone:954-900-4686
Mailing Address - Fax:954-900-2655
Practice Address - Street 1:4401 N ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-3917
Practice Address - Country:US
Practice Address - Phone:954-900-4686
Practice Address - Fax:954-900-2655
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038929208D00000X, 208VP0014X
FLME85999208VP0000X, 208D00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA038929OtherAMERIGROUP
FLME85999OtherAETNA
GA038929OtherWELLCARE
GA038929OtherCARE SOURCE
FLME85999Medicaid
GA038929OtherAETNA
GA038929Medicaid
GA038929OtherPEACH STATE
FLME85999OtherWELLCARE
FLME85999OtherAMBETTER
GA038929OtherAMBETTER