Healthcare Provider Details

I. General information

NPI: 1831203702
Provider Name (Legal Business Name): BENJAMIN PHILLIP REYNOLDS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43063 PEACOCK MARKET PLZ SUITE 150
CHANTILLY VA
20152-4444
US

IV. Provider business mailing address

43063 PEACOCK MARKET PLZ SUITE 150
CHANTILLY VA
20152-4444
US

V. Phone/Fax

Practice location:
  • Phone: 703-327-0075
  • Fax:
Mailing address:
  • Phone: 703-327-0075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101236283
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: