Provider Demographics
NPI:1801894365
Name:REYNOLDS, DAVID GLENN SR (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLENN
Last Name:REYNOLDS
Suffix:SR
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 1:600 E TAYLOR ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-2881
Mailing Address - Country:US
Mailing Address - Phone:903-893-7170
Mailing Address - Fax:903-893-4372
Practice Address - Street 1:600 E TAYLOR ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-2881
Practice Address - Country:US
Practice Address - Phone:903-893-7170
Practice Address - Fax:903-893-4372
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6541174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100146190AOtherOKLAHOMA MEDICAID
LA1736996Medicaid
TX185865601Medicaid
TX1668535-01Medicaid
OK200118650AMedicaid
TX00K55ROtherBLUE CROSS BLUE SHIELD
4333749OtherAETNA
TXP00025103OtherRAILROAD MEDICARE
OK241430304OtherOKLAHOMA MEDICARE
TX1668535-01Medicaid
OK400522582Medicare PIN
OK244633902Medicare PIN
TX8A6231Medicare PIN
TX00K55ROtherBLUE CROSS BLUE SHIELD
TX00X016Medicare PIN