Provider Demographics
NPI:1962444307
Name:BOUKNIGHT, REYNARD RONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:REYNARD
Middle Name:RONALD
Last Name:BOUKNIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-353-4830
Mailing Address - Fax:517-432-2134
Practice Address - Street 1:4650 S HAGADORN RD STE 100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5386
Practice Address - Country:US
Practice Address - Phone:517-353-4830
Practice Address - Fax:517-432-2134
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1821251208Medicaid
MI1347358Medicaid
MIC36088118Medicare PIN
MI13300348112Medicare PIN
MIB47119Medicare UPIN