Healthcare Provider Details

I. General information

NPI: 1104801265
Provider Name (Legal Business Name): RONALD S REAGIN SR. DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 A-B S MAIN ST
BAXLEY GA
31515
US

IV. Provider business mailing address

PO BOX 708 656 A-B S MAIN ST
BAXLEY GA
31515-0708
US

V. Phone/Fax

Practice location:
  • Phone: 912-367-5281
  • Fax: 912-367-5240
Mailing address:
  • Phone: 912-367-5281
  • Fax: 912-367-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000613
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: