Healthcare Provider Details

I. General information

NPI: 1114108552
Provider Name (Legal Business Name): LYDIA M JORGE REYNOLDS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE BOX 016960
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE BOX 016960
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-8256
  • Fax: 305-243-8470
Mailing address:
  • Phone: 305-585-8256
  • Fax: 305-243-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME96171
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberME96171
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: