Provider Demographics
NPI:1548353477
Name:REYNOLDS, KENNETH R (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 219975
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64121-9975
Mailing Address - Country:US
Mailing Address - Phone:913-789-4155
Mailing Address - Fax:
Practice Address - Street 1:11140 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-2301
Practice Address - Country:US
Practice Address - Phone:913-492-9675
Practice Address - Fax:913-894-9591
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-15333207P00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E82028Medicare UPIN