Provider Demographics
NPI:1790721777
Name:BARR REYNOLDS, DEMETRA DIANE (MD)
Entity type:Individual
Prefix:DR
First Name:DEMETRA
Middle Name:DIANE
Last Name:BARR REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEMETRA
Other - Middle Name:DIANE
Other - Last Name:BARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:
Practice Address - Street 1:1895 N JASPER DR STE 3
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1632
Practice Address - Country:US
Practice Address - Phone:928-913-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63274207Q00000X
FLME154526207Q00000X
AZ28556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113774000Medicaid
76550Medicare ID - Type Unspecified