Provider Demographics
NPI:1962415067
Name:DY, GEORGE REYES (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:REYES
Last Name:DY
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 1:40 W WELLSBORO ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16933-1411
Mailing Address - Country:US
Mailing Address - Phone:570-662-1945
Mailing Address - Fax:
Practice Address - Street 1:40 W WELLSBORO ST
Practice Address - Street 2:MANSFIELD LAUREL HEALTH CENTER
Practice Address - City:MANSFIELD
Practice Address - State:PA
Practice Address - Zip Code:16933-1411
Practice Address - Country:US
Practice Address - Phone:570-662-2002
Practice Address - Fax:570-662-2025
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040198L207RN0300X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001126034Medicaid
429944FEMMedicare ID - Type Unspecified