Provider Demographics
NPI:1144225913
Name:REYNARD, LAURIE (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:REYNARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 WILSHIRE BLVD # 614
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5704
Mailing Address - Country:US
Mailing Address - Phone:310-453-1266
Mailing Address - Fax:310-453-1426
Practice Address - Street 1:530 WILSHIRE BLVD STE 202B
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1427
Practice Address - Country:US
Practice Address - Phone:310-453-1266
Practice Address - Fax:310-453-1426
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40794207V00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA6447OtherRAILROAD MEDICARE
CAM050376OtherHARBOR- UCLA
A48354Medicare UPIN
CABL340ZMedicare PIN