Provider Demographics
NPI:1023164662
Name:DOUGLAS REYNOLDS OD PA
Entity type:Organization
Organization Name:DOUGLAS REYNOLDS OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-477-1499
Mailing Address - Street 1:460 E NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-1441
Mailing Address - Country:US
Mailing Address - Phone:850-477-1499
Mailing Address - Fax:850-479-3359
Practice Address - Street 1:460 E NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-1441
Practice Address - Country:US
Practice Address - Phone:850-477-1499
Practice Address - Fax:850-479-3359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3828152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDD4676OtherMEDICARE RAILROAD
FL5477360001Medicare NSC
FLDD4676OtherMEDICARE RAILROAD