Provider Demographics
NPI:1780695965
Name:REYNOLDS, WADE D (DO)
Entity type:Individual
Prefix:DR
First Name:WADE
Middle Name:D
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 IVY PARK LANE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-785-4555
Mailing Address - Fax:803-785-4556
Practice Address - Street 1:111 IVY PARK LANE
Practice Address - Street 2:SUITE C
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:864-885-7935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT00273Medicaid
SCT00273Medicaid
SCG167057136Medicare PIN
SCG167054713Medicare PIN
SCG167056125Medicare PIN
SCG167056201Medicare PIN
SCG167056126Medicare PIN