Provider Demographics
NPI:1275524738
Name:REYNOLDS, DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 20TH ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1809
Mailing Address - Country:US
Mailing Address - Phone:865-546-8040
Mailing Address - Fax:
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:SUITE 606
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1809
Practice Address - Country:US
Practice Address - Phone:865-546-8040
Practice Address - Fax:865-541-2787
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35301207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100035759OtherPHP TENNCARE
TN4087759OtherBLUECARE OF TN
TN3865731Medicaid
TN4087759OtherBLUE CROSS OF TN
TNP00168934OtherTRAVELERS MEDICARE
TN100035759OtherPHP TENNCARE
TN4087759OtherBLUE CROSS OF TN