Provider Demographics
NPI:1356544282
Name:GRIFFIN, REGINALD LANE (MD)
Entity type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:LANE
Last Name:GRIFFIN
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 1:1630 SE 18TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5409
Mailing Address - Country:US
Mailing Address - Phone:352-236-5809
Mailing Address - Fax:
Practice Address - Street 1:1630 SE 18TH ST STE 103
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5409
Practice Address - Country:US
Practice Address - Phone:352-236-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN11572208600000X
FLME112612208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022503400Medicaid