Provider Demographics
NPI:1659565240
Name:REYNOLDS, ERIC KEITH (DPM)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:KEITH
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:115 CHRISTOPHER COLUMBUS DR
Mailing Address - Street 2:404
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-5526
Mailing Address - Country:US
Mailing Address - Phone:973-678-1303
Mailing Address - Fax:973-678-1306
Practice Address - Street 1:115 CHRISTOPHER COLUMBUS DR
Practice Address - Street 2:404
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-5526
Practice Address - Country:US
Practice Address - Phone:973-678-1303
Practice Address - Fax:973-678-1306
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006238213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100019366OtherPTAN NUMBER
NY3017645Medicaid