Provider Demographics
NPI:1730413584
Name:REYES, DESIREE MARY (DPM)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:MARY
Last Name:REYES
Suffix:
Gender:F
Credentials:DPM
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 2553
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23609-0553
Mailing Address - Country:US
Mailing Address - Phone:443-735-7542
Mailing Address - Fax:757-884-8099
Practice Address - Street 1:439 YOUNGS MILL LN
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-9002
Practice Address - Country:US
Practice Address - Phone:757-884-8098
Practice Address - Fax:757-884-8099
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301123213E00000X
CT000894213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400078930Medicare PIN