Provider Demographics
NPI:1851366173
Name:REYNOLDS, WAYNE J (DO)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:J
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5659 PARKWAY DR
Mailing Address - Street 2:STE 210
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-3792
Mailing Address - Country:US
Mailing Address - Phone:804-210-1025
Mailing Address - Fax:804-210-1029
Practice Address - Street 1:5659 PARKWAY DR
Practice Address - Street 2:STE 210
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-3792
Practice Address - Country:US
Practice Address - Phone:804-210-1025
Practice Address - Fax:804-210-1029
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102049941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010118433Medicaid
VA005630789Medicaid
VA005829275Medicaid
F37256Medicare UPIN
VA005630789Medicaid
VA930001186Medicare PIN
VA080007073Medicare PIN