Provider Demographics
NPI:1952407330
Name:REYNOLDS, FREDRICK P (OD)
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:P
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572
Mailing Address - Country:US
Mailing Address - Phone:434-846-7822
Mailing Address - Fax:434-846-8107
Practice Address - Street 1:5076 S. AMHERST HIGHWAY
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572
Practice Address - Country:US
Practice Address - Phone:434-846-7822
Practice Address - Fax:434-846-8107
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000182152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21679Medicare UPIN