Provider Demographics
NPI:1093374068
Name:REYNOLDS, SAMANTHA (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 WINBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HASLET
Mailing Address - State:TX
Mailing Address - Zip Code:76052-6112
Mailing Address - Country:US
Mailing Address - Phone:817-526-2012
Mailing Address - Fax:
Practice Address - Street 1:3451 WESTERN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3101
Practice Address - Country:US
Practice Address - Phone:817-847-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9704T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist