Provider Demographics
NPI:1942392873
Name:REYNOLDS, GERALD EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:EDWARD
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:E
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:10250 SE 167TH PLACE RD
Mailing Address - Street 2:SUITE 5-1
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8686
Mailing Address - Country:US
Mailing Address - Phone:352-307-9925
Mailing Address - Fax:352-347-1703
Practice Address - Street 1:4685 N HIGHWAY 19A
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2039
Practice Address - Country:US
Practice Address - Phone:352-589-5900
Practice Address - Fax:352-589-5904
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038568900Medicaid
FL080130087OtherMEDICARE RAILROAD
FL038568900Medicaid
FL82299Medicare ID - Type Unspecified
FL038568900Medicaid
FL080130087OtherMEDICARE RAILROAD