Provider Demographics
NPI:1063640043
Name:REYNOLDS, KEVIN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
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 1:15330 INTERSTATE 35 N
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-3814
Mailing Address - Country:US
Mailing Address - Phone:210-658-9133
Mailing Address - Fax:
Practice Address - Street 1:15330 INTERSTATE 35 N
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:TX
Practice Address - Zip Code:78154-3814
Practice Address - Country:US
Practice Address - Phone:210-658-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7515TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist