Provider Demographics
NPI:1669464244
Name:REYNOLDS, MARK STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:14215 BALLANTYNE CORPORATE PARK
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-384-1950
Practice Address - Fax:704-384-1955
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200300689208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0068GMedicaid
NC89134U9Medicaid
NC89134U9Medicaid