Provider Demographics
NPI:1174691489
Name:REYNOLDS, PAUL D (DPM)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:D
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2858 MAHAN DR
Mailing Address - Street 2:SUITE 1 & 2
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5446
Mailing Address - Country:US
Mailing Address - Phone:850-942-0096
Mailing Address - Fax:
Practice Address - Street 1:1580 WALDO PALMER LN STE 1A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-6049
Practice Address - Country:US
Practice Address - Phone:850-942-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2918213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340286000Medicaid
FL65748YMedicare PIN
U91126Medicare UPIN