Healthcare Provider Details

I. General information

NPI: 1457364663
Provider Name (Legal Business Name): PETER MCLEAN REYNOLDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 JADE ST SUITE 100
CAPITOLA CA
95010-3956
US

IV. Provider business mailing address

3803 S BASCOM AVE SUITE 102
CAMPBELL CA
95008-7317
US

V. Phone/Fax

Practice location:
  • Phone: 831-475-4024
  • Fax: 831-475-4344
Mailing address:
  • Phone: 831-475-4024
  • Fax: 831-475-4344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberC384340
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: