Provider Demographics
NPI:1912997859
Name:REYNOLDS, TERRY L (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
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:P.O. BOX 1213
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31521-1213
Mailing Address - Country:US
Mailing Address - Phone:912-466-1217
Mailing Address - Fax:912-466-1213
Practice Address - Street 1:2415 PARKWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4722
Practice Address - Country:US
Practice Address - Phone:912-466-1217
Practice Address - Fax:912-466-1213
Is Sole Proprietor?:No
Enumeration Date:2005-10-23
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0217932085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000233725DMedicaid
GA30BDKZCMedicare ID - Type Unspecified
GA000233725DMedicaid