Provider Demographics
NPI:1811975634
Name:REYNOLDS, CLYDE DOUGLAS (OD)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:DOUGLAS
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:DOUGLAS
Other - Middle Name:
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:460 E NINE MILE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-1441
Mailing Address - Country:US
Mailing Address - Phone:850-477-1499
Mailing Address - Fax:850-479-3359
Practice Address - Street 1:460 E NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-1441
Practice Address - Country:US
Practice Address - Phone:850-477-1499
Practice Address - Fax:850-479-3359
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3828152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45012OtherBCBS PROVIDER NUMBER
FLP00229829OtherMEDICARE RAILROAD
FL45012AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FLK7607Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER
FLU98238Medicare UPIN