Provider Demographics
NPI:1295099570
Name:REYNOLDS, SEAN (MB BCH BAO)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MB BCH BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3011
Mailing Address - Country:US
Mailing Address - Phone:415-353-7880
Mailing Address - Fax:
Practice Address - Street 1:1701 DIVISADERO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-353-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-01
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264533208000000X
RILP03737207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics