Provider Demographics
NPI:1568416386
Name:REYNOLDS, MELISSA L (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
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 1:333 17TH STREET
Mailing Address - Street 2:SUITE O
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960
Mailing Address - Country:US
Mailing Address - Phone:772-581-6226
Mailing Address - Fax:772-581-5771
Practice Address - Street 1:333 17TH STREET
Practice Address - Street 2:SUITE O
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-581-6226
Practice Address - Fax:772-581-5771
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53428207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07217Medicare PIN
FL07217Medicare ID - Type Unspecified
B62131Medicare UPIN