Provider Demographics
NPI:1487604021
Name:REYNOLDS, MICHAEL B (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 ENOTA DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2437
Mailing Address - Country:US
Mailing Address - Phone:770-538-0208
Mailing Address - Fax:770-538-0556
Practice Address - Street 1:605 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2437
Practice Address - Country:US
Practice Address - Phone:770-538-0208
Practice Address - Fax:770-538-0556
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046224207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1487604021OtherBCBS
GACH9982OtherRAILROAD MEDICARE
GA0007735230OtherAETNA
GA070015990OtherRAILROAD MEDICARE
GA000814767AMedicaid
GA0007735230OtherAETNA
GACH9982OtherRAILROAD MEDICARE
GA1487604021OtherBCBS