Provider Demographics
NPI:1871598920
Name:REYES, MIRABELLE (DO)
Entity type:Individual
Prefix:
First Name:MIRABELLE
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MIRABELLE
Other - Middle Name:REYES
Other - Last Name:DEMUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:639 N MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1931
Mailing Address - Country:US
Mailing Address - Phone:270-737-4600
Mailing Address - Fax:270-737-1722
Practice Address - Street 1:639 N MULBERRY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1931
Practice Address - Country:US
Practice Address - Phone:270-737-4600
Practice Address - Fax:270-737-1722
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02887207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64101090Medicaid
KY0336333Medicare PIN
KY64101090Medicaid