Provider Demographics
NPI:1790721777
Name:BARR REYNOLDS, DEMETRA DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRA
Middle Name:DIANE
Last Name:BARR REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEMETRA
Other - Middle Name:DIANE
Other - Last Name:BARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7100
Mailing Address - Fax:239-343-7190
Practice Address - Street 1:16271 BASS RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3616
Practice Address - Country:US
Practice Address - Phone:239-343-7100
Practice Address - Fax:239-343-7190
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28556207Q00000X
CAA63274207Q00000X
FLME154526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113774000Medicaid
76550Medicare ID - Type Unspecified