Provider Demographics
NPI:1447438940
Name:GONZALEZ REYES, LYDIARIS (MD)
Entity type:Individual
Prefix:DR
First Name:LYDIARIS
Middle Name:
Last Name:GONZALEZ REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LYDIARIS
Other - Middle Name:
Other - Last Name:GONZALEZ REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:UTUADO
Mailing Address - State:PR
Mailing Address - Zip Code:00641-0277
Mailing Address - Country:US
Mailing Address - Phone:787-205-7644
Mailing Address - Fax:
Practice Address - Street 1:GOLDEN HILLS C/LOS ASTROS #5
Practice Address - Street 2:
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646-0064
Practice Address - Country:US
Practice Address - Phone:787-665-6531
Practice Address - Fax:787-905-7281
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16936208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$Medicaid