Provider Demographics
NPI:1134104896
Name:REYNOLDS, KAREN E (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:E
Last Name: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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:608 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1702
Practice Address - Country:US
Practice Address - Phone:920-324-6853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53827208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34532800Medicaid
WIP00893766OtherRAILROAD MEDICARE
WIP00893766OtherRAILROAD MEDICARE
WI161300114Medicare PIN
P00214233Medicare PIN