Provider Demographics
NPI:1760475545
Name:REYNOLDS, DWIGHT RAYMOND (MD)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:RAYMOND
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 1:811 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-2507
Mailing Address - Country:US
Mailing Address - Phone:803-359-8855
Mailing Address - Fax:803-359-1257
Practice Address - Street 1:811 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2507
Practice Address - Country:US
Practice Address - Phone:803-359-8855
Practice Address - Fax:803-359-1257
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC013522208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC135222Medicaid
N47422Medicare UPIN