=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720120843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH UNDERHILL REYNOLDS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 09/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 E BIJOU ST
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-434-2061
-----------------------------------------------------
Fax | 719-434-2275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6938
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80934-6938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-338-7777
-----------------------------------------------------
Fax | 719-634-5549
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 23321
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------