Provider Demographics
NPI:1972597441
Name:REYES, MARILOU (MD)
Entity type:Individual
Prefix:
First Name:MARILOU
Middle Name:
Last Name:REYES
Suffix:
Gender:F
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:PO BOX 23245
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86439-3245
Mailing Address - Country:US
Mailing Address - Phone:928-763-7020
Mailing Address - Fax:928-763-7050
Practice Address - Street 1:2585 MIRACLE MILE
Practice Address - Street 2:SUITE 126
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7522
Practice Address - Country:US
Practice Address - Phone:928-763-7020
Practice Address - Fax:928-763-7050
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ787434Medicaid
H84463Medicare UPIN
AZ787434Medicaid