Provider Demographics
NPI:1528045846
Name:REYNOLDS, KELLEY M (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:M
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:500 SOUTH JOHNSON DRIVE
Practice Address - Street 2:
Practice Address - City:MCGREGOR
Practice Address - State:TX
Practice Address - Zip Code:76657
Practice Address - Country:US
Practice Address - Phone:254-313-5200
Practice Address - Fax:254-313-4531
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102807803Medicaid
TX8D2331Medicare ID - Type Unspecified
TXG67751Medicare UPIN