Provider Demographics
NPI:1538194352
Name:DE LOS REYES, BERNARDITA L (MD)
Entity type:Individual
Prefix:DR
First Name:BERNARDITA
Middle Name:L
Last Name:DE LOS 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 1159
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90240-0159
Mailing Address - Country:US
Mailing Address - Phone:323-587-2222
Mailing Address - Fax:323-587-3963
Practice Address - Street 1:2760 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5747
Practice Address - Country:US
Practice Address - Phone:323-587-2222
Practice Address - Fax:323-587-3963
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37605174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A376050Medicaid
CAWA37605CMedicare PIN