Provider Demographics
NPI:1174527568
Name:REYNOLDS, RONALD R (OD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:R
Last Name:REYNOLDS
Suffix:
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 1:95-390 KUAHELANI AVE
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-1192
Mailing Address - Country:US
Mailing Address - Phone:808-623-2866
Mailing Address - Fax:808-623-2755
Practice Address - Street 1:95-390 KUAHELANI AVE
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1192
Practice Address - Country:US
Practice Address - Phone:808-623-2866
Practice Address - Fax:808-623-2755
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-03-14
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
HI112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI05147901Medicaid
HIDQ453AMedicare PIN
HI05147901Medicaid
HI0678930001Medicare NSC