Provider Demographics
NPI:1598965162
Name:REYNOLDS, JOSEPH (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 GRAND AVE STE 14
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-4259
Mailing Address - Country:US
Mailing Address - Phone:406-259-6786
Mailing Address - Fax:
Practice Address - Street 1:1212 GRAND AVE STE 14
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102
Practice Address - Country:US
Practice Address - Phone:406-259-6786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003472A152W00000X
KY1708DT152W00000X
MT3381152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1598965162Medicaid