Provider Demographics
NPI:1740202290
Name:REYNOLDS, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
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:P O BOX 2595
Mailing Address - Street 2:130 N BROAD ST
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799
Mailing Address - Country:US
Mailing Address - Phone:256-238-6035
Mailing Address - Fax:
Practice Address - Street 1:1500 E SHOTWELL ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4256
Practice Address - Country:US
Practice Address - Phone:229-243-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040207207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG05900Medicare UPIN