Provider Demographics
NPI: | 1144225913 |
---|---|
Name: | REYNARD, LAURIE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | LAURIE |
Middle Name: | |
Last Name: | REYNARD |
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: | 2118 WILSHIRE BLVD # 614 |
Mailing Address - Street 2: | |
Mailing Address - City: | SANTA MONICA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90403-5704 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-453-1266 |
Mailing Address - Fax: | 310-453-1426 |
Practice Address - Street 1: | 530 WILSHIRE BLVD STE 202B |
Practice Address - Street 2: | |
Practice Address - City: | SANTA MONICA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90401-1427 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-453-1266 |
Practice Address - Fax: | 310-453-1426 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-16 |
Last Update Date: | 2018-02-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G40794 | 207V00000X |
174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | DA6447 | Other | RAILROAD MEDICARE |
CA | M050376 | Other | HARBOR- UCLA |
A48354 | Medicare UPIN | ||
CA | BL340Z | Medicare PIN |