1801894365 NPI number — DR. DAVID GLENN REYNOLDS SR. MD

Table of content: LUCAS DAVIS MHPP (NPI 1154641819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801894365 NPI number — DR. DAVID GLENN REYNOLDS SR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
DAVID
Provider Middle Name:
GLENN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801894365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 E TAYLOR ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
SHERMAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75090-2881
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-893-7170
Provider Business Mailing Address Fax Number:
903-893-4372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 E TAYLOR ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SHERMAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75090-2881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-893-7170
Provider Business Practice Location Address Fax Number:
903-893-4372
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  H6541 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: H6541 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100146190A . This is a "OKLAHOMA MEDICAID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 1736996 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 185865601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1668535-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200118650A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00K55R . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4333749 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00025103 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 241430304 . This is a "OKLAHOMA MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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