Provider Demographics
NPI:1205001658
Name:REYNOLDS, KENNETH HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:HOWARD
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:PO BOX 2239
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224
Mailing Address - Country:US
Mailing Address - Phone:970-349-7341
Mailing Address - Fax:
Practice Address - Street 1:24 WHETSTONE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CRESTED BUTTE
Practice Address - State:CO
Practice Address - Zip Code:81225
Practice Address - Country:US
Practice Address - Phone:970-349-7341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14826207R00000X
GA09598207R00000X
IDM7415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D40960Medicare UPIN