Provider Demographics
NPI:1851478481
Name:REYNARD, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REYNARD
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 1:1301 20TH ST STE 260
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2052
Mailing Address - Country:US
Mailing Address - Phone:310-453-0551
Mailing Address - Fax:310-315-0133
Practice Address - Street 1:1301 20TH ST STE 260
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2052
Practice Address - Country:US
Practice Address - Phone:310-453-0551
Practice Address - Fax:310-315-0133
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40986207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG40986Medicare PIN
CAA48420Medicare UPIN