Provider Demographics
NPI:1407845712
Name:REYNOLDS, OWEN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:DAVID
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:280 MERRIMACK ST STE 311
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1779
Mailing Address - Country:US
Mailing Address - Phone:978-691-5690
Mailing Address - Fax:978-691-5693
Practice Address - Street 1:198 MASSACHUSETTS AVE STE 105
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-4143
Practice Address - Country:US
Practice Address - Phone:978-691-5690
Practice Address - Fax:978-691-5693
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74177207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3102769Medicaid
MAA16757Medicare ID - Type Unspecified