Provider Demographics
NPI:1497418651
Name:REYNOLDS, ELIZAVETA
Entity Type:Individual
Prefix:
First Name:ELIZAVETA
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13248 ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-6752
Mailing Address - Country:US
Mailing Address - Phone:917-539-9098
Mailing Address - Fax:
Practice Address - Street 1:13248 ROGERS RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-6752
Practice Address - Country:US
Practice Address - Phone:917-539-9098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D2237496207RI0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory Immunology