Provider Demographics
NPI:1164442711
Name:REYNOLDS, FREDERICK DIETER (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:DIETER
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 1:1 WEST AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-6045
Mailing Address - Country:US
Mailing Address - Phone:518-693-4418
Mailing Address - Fax:518-693-4481
Practice Address - Street 1:1 WEST AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-6045
Practice Address - Country:US
Practice Address - Phone:518-693-4418
Practice Address - Fax:518-693-4481
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232317208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02638411Medicaid
NY02638411Medicaid
NYI28776Medicare UPIN
NY000415487001OtherBLUE SHIELD NENY
NYRA6331Medicare ID - Type Unspecified