Provider Demographics
NPI:1497793632
Name:REYNOLDS, MARK DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5409 AVENUE O
Mailing Address - Street 2:SUITE 118
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9601
Mailing Address - Country:US
Mailing Address - Phone:319-372-9292
Mailing Address - Fax:319-372-3025
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:SUITE 118
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-372-9292
Practice Address - Fax:319-372-3025
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-07-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA29979207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0102OtherJOHN DEERE HEALTHCARE
MO207737800Medicaid
IA1113118Medicaid
22227OtherIOWA HEALTH SOLUTIONS
MO207737800Medicaid
22227OtherIOWA HEALTH SOLUTIONS
IA1113118Medicaid