Provider Demographics
NPI:1457364663
Name:REYNOLDS, PETER MCLEAN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MCLEAN
Last Name:REYNOLDS
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 1:3803 S BASCOM AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7317
Mailing Address - Country:US
Mailing Address - Phone:831-475-4024
Mailing Address - Fax:831-475-4344
Practice Address - Street 1:4140 JADE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3956
Practice Address - Country:US
Practice Address - Phone:831-475-4024
Practice Address - Fax:831-475-4344
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC384340207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC384340OtherMEDICAL LIC
CA00C384340Medicare ID - Type Unspecified
CAC384340OtherMEDICAL LIC