Provider Demographics
NPI:1134754294
Name:REYNOLDS, DOROTHY (LO)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2406
Mailing Address - Country:US
Mailing Address - Phone:203-372-2010
Mailing Address - Fax:203-372-2011
Practice Address - Street 1:2480 BLACK ROCK TPK
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-2406
Practice Address - Country:US
Practice Address - Phone:203-372-2010
Practice Address - Fax:203-372-2011
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001411156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician