Provider Demographics
NPI:1033144118
Name:REYNOLDS, D ENISE W (MD)
Entity Type:Individual
Prefix:DR
First Name:D ENISE
Middle Name:W
Last Name:REYNOLDS
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 1:3688 VETERANS MEMORIAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8246
Mailing Address - Country:US
Mailing Address - Phone:601-554-7402
Mailing Address - Fax:601-554-7488
Practice Address - Street 1:3688 VETERANS MEMORIAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8246
Practice Address - Country:US
Practice Address - Phone:601-554-7402
Practice Address - Fax:601-554-7488
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12044207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010036Medicaid
E02467Medicare UPIN
MS050000824Medicare ID - Type Unspecified