Provider Demographics
NPI:1922426360
Name:REAVES, DAVID LEE JR
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:REAVES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:LEE
Other - Last Name:REAVES
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:P.O BOX 703
Mailing Address - Street 2:322 MILLEDGEVILLE HIGHWAY
Mailing Address - City:GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:31031
Mailing Address - Country:US
Mailing Address - Phone:478-628-4007
Mailing Address - Fax:478-628-4007
Practice Address - Street 1:322 MILLEDGEVILLE HWY
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:GA
Practice Address - Zip Code:31031-4177
Practice Address - Country:US
Practice Address - Phone:478-628-4007
Practice Address - Fax:478-628-4007
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA332B00000XOtherN/A