Provider Demographics
NPI:1225012875
Name:REYNDERS, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:REYNDERS
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 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5753
Mailing Address - Country:US
Mailing Address - Phone:920-430-4700
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30754500Medicaid
WI28059OtherLICENSE
WI075100003Medicare Oscar/Certification
WIB56013Medicare UPIN
WI000056Medicare Oscar/Certification
WI080075417Medicare PIN
WI000307510Medicare Oscar/Certification