Provider Demographics
NPI:1801952064
Name:REYNOLDS, ROY B (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:B
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8201 BRITTON AVE
Mailing Address - Street 2:#3R
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2434
Mailing Address - Country:US
Mailing Address - Phone:718-672-0083
Mailing Address - Fax:718-672-9885
Practice Address - Street 1:8201 BRITTON AVE
Practice Address - Street 2:#3R
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2434
Practice Address - Country:US
Practice Address - Phone:718-672-0083
Practice Address - Fax:718-672-9885
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY163521207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMM15910421Medicaid
NYMM15910421Medicaid
NY58D48100Medicare ID - Type Unspecified