Provider Demographics
NPI:1972589174
Name:REYNEN, PAUL D (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:REYNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 DIAGONAL RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1008
Mailing Address - Country:US
Mailing Address - Phone:507-372-3800
Mailing Address - Fax:507-372-3806
Practice Address - Street 1:1680 DIAGONAL RD
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1008
Practice Address - Country:US
Practice Address - Phone:507-372-3800
Practice Address - Fax:507-372-3706
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35809207X00000X, 207X00000X
SD3543207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6400662Medicaid
SD6400662Medicaid
SDP00334465Medicare PIN
SDS101904Medicare PIN