Provider Demographics
NPI:1285675942
Name:REYNOLDS, DAVID T (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4136
Mailing Address - Country:US
Mailing Address - Phone:405-372-3724
Mailing Address - Fax:405-743-1042
Practice Address - Street 1:2123 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4136
Practice Address - Country:US
Practice Address - Phone:405-372-3724
Practice Address - Fax:405-743-1042
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2051152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200005020AMedicaid
OK0210790001OtherPALMETTO GOVERNMENT BENEFITS ADMINISTRATORS
OK410032462OtherRAILROAD MEDICARE
OK0210790001Medicare NSC
OK410032462OtherRAILROAD MEDICARE