Provider Demographics
NPI:1114108552
Name:JORGE REYNOLDS, LYDIA M (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:JORGE REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 NW 12TH AVE
Mailing Address - Street 2:BOX 016960
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-585-8256
Mailing Address - Fax:305-243-8470
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:BOX 016960
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-8256
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96171207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2803381-00Medicaid
FLAI374ZMedicare PIN