Provider Demographics
NPI:1427130574
Name:DE LOS REYES, WILLETA R (MD)
Entity type:Individual
Prefix:DR
First Name:WILLETA
Middle Name:R
Last Name:DE LOS REYES
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:5800 3RD AVE
Mailing Address - Street 2:MANAGED CARE DEPARTMENT
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3702
Mailing Address - Country:US
Mailing Address - Phone:718-630-7477
Mailing Address - Fax:718-630-7437
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:SUNSET PARK FAMILY HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2559
Practice Address - Country:US
Practice Address - Phone:718-630-7942
Practice Address - Fax:718-630-7251
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-08-06
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Provider Licenses
StateLicense IDTaxonomies
NY113370208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00205761Medicaid
NY00205761Medicaid
NY641591Medicare ID - Type Unspecified