Provider Demographics
NPI:1275682908
Name:MCREYNOLDS, LORIE MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:LORIE
Middle Name:MICHELLE
Last Name:MCREYNOLDS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11023 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-1254
Mailing Address - Country:US
Mailing Address - Phone:314-821-8999
Mailing Address - Fax:314-821-9008
Practice Address - Street 1:11023 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-1254
Practice Address - Country:US
Practice Address - Phone:314-821-8999
Practice Address - Fax:314-821-9008
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU89920Medicare UPIN