Provider Demographics
NPI:1417020348
Name:REYNOLDS, LAWRENCE LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:LEWIS
Last Name:REYNOLDS
Suffix:
Gender:M
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:DRAWER J
Mailing Address - Street 2:252 SELDOVIA ST
Mailing Address - City:SELDOVIA
Mailing Address - State:AK
Mailing Address - Zip Code:99663-0210
Mailing Address - Country:US
Mailing Address - Phone:907-234-7825
Mailing Address - Fax:907-234-7825
Practice Address - Street 1:252 SELDOVIA ST
Practice Address - Street 2:
Practice Address - City:SELDOVIA
Practice Address - State:AK
Practice Address - Zip Code:99663-0210
Practice Address - Country:US
Practice Address - Phone:907-234-7825
Practice Address - Fax:907-234-7825
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1164208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1164Medicaid
0200641039OtherCLIA
0200641039OtherCLIA
0000BHDSLMedicare ID - Type Unspecified