Provider Demographics
NPI:1689686065
Name:REYNOLDS, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12266 DEPAUL DR.
Practice Address - Street 2:SUITE 305
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2516
Practice Address - Country:US
Practice Address - Phone:314-770-0991
Practice Address - Fax:314-770-0692
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1J28208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO770001238OtherRAILROAD MEDICARE
MO202545612Medicaid