Provider Demographics
NPI:1942275961
Name:REYNOLDS, DANIEL W (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:WILLIAM
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 130
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2583
Practice Address - Country:US
Practice Address - Phone:763-236-9000
Practice Address - Fax:763-236-9010
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53998208600000X
MN36923208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN246225700Medicaid
WI34090600Medicaid
WI34090600Medicaid
F80318Medicare UPIN