Provider Demographics
NPI:1174516298
Name:REYNOLDS, WILLIAM T JR (OD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:REYNOLDS
Suffix:JR
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 1:1020 GIBSON BAY DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3448
Mailing Address - Country:US
Mailing Address - Phone:859-623-3358
Mailing Address - Fax:859-623-8141
Practice Address - Street 1:1020 GIBSON BAY DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3448
Practice Address - Country:US
Practice Address - Phone:859-623-3358
Practice Address - Fax:859-623-8141
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1069 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000051583OtherANTHEM
KY1069 DTOtherOPTOMETRIC LICENSE
KY77010692Medicaid
KY410040399OtherRAILROAD
KY4357622OtherAETNA
KY1312022OtherCIGNA
KY1312022OtherCIGNA
KY4357622OtherAETNA
KY0371801Medicare PIN