Provider Demographics
NPI:1942346911
Name:REYNOLDS, BRETT (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 S HIGHWAY A1A STE 11
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3152
Mailing Address - Country:US
Mailing Address - Phone:321-308-2015
Mailing Address - Fax:321-308-2017
Practice Address - Street 1:3830 S HIGHWAY A1A STE 11
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-3152
Practice Address - Country:US
Practice Address - Phone:321-308-2015
Practice Address - Fax:321-308-2017
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410043221OtherRR MEDICARE
410045559OtherRR MEDICARE
FL20933OtherBCBS
FL20933OtherBCBS
FLU78190Medicare UPIN
FL1326760001Medicare NSC
FLE3434Medicare PIN