Provider Demographics
NPI:1043271679
Name:REYENGA, STANLEY LOUIS (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:LOUIS
Last Name:REYENGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:STAN
Other - Middle Name:L
Other - Last Name:REYENGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:1311 SOUTH I ST.
Practice Address - Street 2:ER DEPT.
Practice Address - City:FT. SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901
Practice Address - Country:US
Practice Address - Phone:479-441-5011
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4992207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE54515Medicare UPIN
AR56387Medicare ID - Type Unspecified