Provider Demographics
NPI:1336571843
Name:REYNOLDS, CARRIE M (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:M
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SCENIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 SCENIC VIEW DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-394-7416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1115648-63538208600000X
CT60596208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery