Provider Demographics
NPI:1386628162
Name:REYNOLDS, TERRENCE J (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:J
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 1:6700 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8727
Mailing Address - Country:US
Mailing Address - Phone:208-336-7100
Mailing Address - Fax:208-321-2710
Practice Address - Street 1:6700 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8727
Practice Address - Country:US
Practice Address - Phone:208-336-7100
Practice Address - Fax:208-321-2710
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002692102Medicaid
ID20006383Medicare PIN
ID002692102Medicaid
ID0640190001Medicare NSC