Provider Demographics
NPI:1831129238
Name:REYNOLDS, JON WELLINGTON (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:WELLINGTON
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-8190
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-8190
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301404207LP2900X
NC2003-01404207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1425ROtherBCBS
190682OtherMEDCOST
7897877OtherAETNA
SCQ0140HMedicaid
NC5904515Medicaid
WV3810008337Medicaid
P00397986OtherRR MEDICARE
808416OtherPARTNERS
2063885Medicare PIN