Provider Demographics
NPI:1518282920
Name:REYNOLDS, KERISIMASI L (DO)
Entity Type:Individual
Prefix:
First Name:KERISIMASI
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DO
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Other - First Name:
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Mailing Address - Street 1:39180 FARWELL DR STE 110
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1015
Mailing Address - Country:US
Mailing Address - Phone:510-739-6520
Mailing Address - Fax:510-739-6522
Practice Address - Street 1:39180 FARWELL DR STE 110
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1015
Practice Address - Country:US
Practice Address - Phone:510-739-6520
Practice Address - Fax:510-739-6522
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A13974207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine