Provider Demographics
NPI:1043226178
Name:REYNOLDS, KENT DOUGLAS (OD)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:DOUGLAS
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 14TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-6956
Mailing Address - Country:US
Mailing Address - Phone:541-928-1667
Mailing Address - Fax:541-928-1817
Practice Address - Street 1:2700 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6956
Practice Address - Country:US
Practice Address - Phone:541-928-1667
Practice Address - Fax:541-928-1817
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1285152W00000X
OR3022ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025040Medicaid
MD983001400Medicaid
MDU83069Medicare UPIN
MDKN3568TTMedicare ID - Type Unspecified
OR025040Medicaid
ORR143166Medicare PIN