Healthcare Provider Details

I. General information

NPI: 1205001658
Provider Name (Legal Business Name): KENNETH HOWARD REYNOLDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 WHETSTONE DR
MOUNT CRESTED BUTTE CO
81225
US

IV. Provider business mailing address

PO BOX 2239
CRESTED BUTTE CO
81224
US

V. Phone/Fax

Practice location:
  • Phone: 970-349-7341
  • Fax:
Mailing address:
  • Phone: 970-349-7341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14826
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number09598
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM7415
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: