Provider Demographics
NPI:1194767954
Name:REYES, GERARDO (MD, MBA)
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:REYES
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 931968
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-1968
Mailing Address - Country:US
Mailing Address - Phone:912-350-8016
Mailing Address - Fax:912-350-7221
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31403-3089
Practice Address - Country:US
Practice Address - Phone:912-350-8016
Practice Address - Fax:912-350-7221
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH38352080P0203X
NC2014-021242080P0203X
NMMD2023-11752080P0203X
FLME1236132080P0203X
GA0591792080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG59179Medicaid
GA315942089AMedicaid
IL036-091219Medicaid
ILE90529Medicare UPIN