Provider Demographics
NPI:1588624670
Name:REYNOLDS, ROY D (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:D
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134
Mailing Address - Country:US
Mailing Address - Phone:270-586-9581
Mailing Address - Fax:270-586-6261
Practice Address - Street 1:121 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134
Practice Address - Country:US
Practice Address - Phone:270-586-9581
Practice Address - Fax:270-586-6261
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64193832Medicaid
KY64193832Medicaid
C65334Medicare UPIN