Provider Demographics
NPI:1073514709
Name:REID, KEVIN M (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:REID
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W GRAND AVE
Mailing Address - Street 2:SUITE 2001
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-4775
Mailing Address - Country:US
Mailing Address - Phone:937-226-7887
Mailing Address - Fax:937-224-5098
Practice Address - Street 1:425 W GRAND AVE
Practice Address - Street 2:SUITE 2001
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4775
Practice Address - Country:US
Practice Address - Phone:937-226-7887
Practice Address - Fax:937-224-5098
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002459R204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000008389OtherANTHEM BLUE SHIELD
OH0396076Medicaid
OHD89753Medicare UPIN
OH0396076Medicaid