Provider Demographics
NPI:1043277270
Name:REYNOLDS, HARRY RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:RICHARD
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 CHESTERFIELD AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1062
Mailing Address - Country:US
Mailing Address - Phone:304-345-3570
Mailing Address - Fax:304-345-3599
Practice Address - Street 1:2345 CHESTERFIELD AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1062
Practice Address - Country:US
Practice Address - Phone:304-345-3570
Practice Address - Fax:304-345-3599
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV14661207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV51D0234293OtherCLIA
WV55-0672861OtherTAX ID
WVWV14661OtherWV LICENSE
WV0069872000Medicaid
WVBRO446383OtherDEA
WV55-0672861OtherTAX ID
WVWV14661OtherWV LICENSE