Provider Demographics
NPI:1689670689
Name:REYNOLDS, KATHRYN (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:1729 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4977
Practice Address - Country:US
Practice Address - Phone:636-733-0090
Practice Address - Fax:636-733-0028
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO313710501Medicaid
U35045Medicare UPIN
MO006006438Medicare ID - Type Unspecified