Provider Demographics
NPI:1215027305
Name:JOHN, REYNOLD M (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:REYNOLD
Middle Name:M
Last Name:JOHN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 JORDAN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5628
Mailing Address - Country:US
Mailing Address - Phone:248-879-9438
Mailing Address - Fax:
Practice Address - Street 1:43171 DALCOMA DR
Practice Address - Street 2:SUITE #6
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6307
Practice Address - Country:US
Practice Address - Phone:586-286-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301094Medicaid
MI4301405724OtherLICENSE #
MIBJ1161645OtherDEA #
MI4301094Medicaid
MIBJ1161645OtherDEA #