Healthcare Provider Details

I. General information

NPI: 1730355967
Provider Name (Legal Business Name): JUDD M REYNOLDS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PARKWAY LN
PETAL MS
39465-3035
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-7404
  • Fax: 601-579-5240
Mailing address:
  • Phone: 601-544-7404
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA2169
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24473
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: