Provider Demographics
NPI:1386846319
Name:REYES, INGRID VIVIAN (MD)
Entity type:Individual
Prefix:DR
First Name:INGRID
Middle Name:VIVIAN
Last Name:REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:INGRID
Other - Middle Name:VIVIAN
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10692 MEDLOCK BRIDGE RD STE 100A
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8497
Mailing Address - Country:US
Mailing Address - Phone:404-446-2496
Mailing Address - Fax:404-446-2497
Practice Address - Street 1:10692 MEDLOCK BRIDGE RD STE 100A
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8497
Practice Address - Country:US
Practice Address - Phone:404-446-2496
Practice Address - Fax:404-446-2497
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064059207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA MCD PENDINGMedicaid
GAGA MCD PENDINGMedicaid