Provider Demographics
NPI:1679653174
Name:REAGIN, RICHARD STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:STEPHEN
Last Name:REAGIN
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 1:104 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3325
Mailing Address - Country:US
Mailing Address - Phone:404-378-3694
Mailing Address - Fax:404-373-0741
Practice Address - Street 1:104 CHURCH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3325
Practice Address - Country:US
Practice Address - Phone:404-378-3694
Practice Address - Fax:404-373-0741
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1149T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000368002BMedicaid
GA000368002BMedicaid
GA0164490001Medicare NSC
GA41ZCBXSMedicare PIN
GA000368002BMedicaid