Provider Demographics
NPI:1619931367
Name:IAN JOHN REYNOLDS MD PA
Entity Type:Organization
Organization Name:IAN JOHN REYNOLDS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:I
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-332-9676
Mailing Address - Street 1:450 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598
Mailing Address - Country:US
Mailing Address - Phone:281-332-9676
Mailing Address - Fax:281-338-7723
Practice Address - Street 1:450 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598
Practice Address - Country:US
Practice Address - Phone:281-332-9676
Practice Address - Fax:281-338-7723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDF8994207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099487301Medicaid
TX099487301Medicaid
B25901Medicare UPIN
TXTXB107066Medicare PIN