Provider Demographics
NPI:1831651181
Name:REYNAL, SHANE DOUGLAS
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:DOUGLAS
Last Name:REYNAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7832 PAT BOOKER RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2601
Mailing Address - Country:US
Mailing Address - Phone:210-657-9338
Mailing Address - Fax:
Practice Address - Street 1:7832 PAT BOOKER RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-2601
Practice Address - Country:US
Practice Address - Phone:210-657-9338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU2302207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology