Provider Demographics
NPI:1114905304
Name:REYNOLDS, SAM DAVID (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:DAVID
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 1:12311 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8344
Mailing Address - Country:US
Mailing Address - Phone:878-332-4159
Mailing Address - Fax:878-332-4479
Practice Address - Street 1:12311 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8344
Practice Address - Country:US
Practice Address - Phone:878-332-4159
Practice Address - Fax:878-332-4479
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071994L207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11011503OtherCAQH
PA001853530Medicaid