Provider Demographics
NPI:1861426272
Name:REYNOLDS, JOHN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:155 SPURWINK AVE
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-9604
Practice Address - Country:US
Practice Address - Phone:207-767-2174
Practice Address - Fax:207-767-1348
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME284170099Medicaid
MEMM537601Medicare PIN
MEF78931Medicare UPIN
MEMM5376Medicare PIN
ME284170099Medicaid
MEMM573602Medicare PIN