Provider Demographics
NPI:1598717647
Name:MCREYNOLDS, KEITH E (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:MCREYNOLDS
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 1:1460 E COLT ROAD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284
Mailing Address - Country:US
Mailing Address - Phone:480-227-0500
Mailing Address - Fax:
Practice Address - Street 1:1460 E COLT ROAD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284
Practice Address - Country:US
Practice Address - Phone:480-227-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9169207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSTATE LICENSE # 9169OtherAZ MEDICAL BOARD
AZSTATE LICENSE # 9169OtherAZ MEDICAL BOARD