Provider Demographics
NPI:1215588322
Name:REYNGOUDT, MARY M
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:REYNGOUDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 GILMAN RD
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14428-9325
Mailing Address - Country:US
Mailing Address - Phone:585-530-0515
Mailing Address - Fax:
Practice Address - Street 1:149 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1434
Practice Address - Country:US
Practice Address - Phone:585-377-2230
Practice Address - Fax:585-377-2243
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist