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General NPI Number Information
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NPI Number | 1982689535
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Entity Type | Individual
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Provider Name | PETER LAWRENCE REYNOLDS M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/07/2005
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Last Update Date | 04/26/2018
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Provider Practice Location Address
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Address Line | 725 UNIVERSITY BLVD
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City | FAIRBORN
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State | OH
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Zip | 45324
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Country | US
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Telephone | 937-245-7100
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Fax | 937-245-7999
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Provider Business Mailing Address
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Address Line | 725 UNIVERSITY BLVD
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City | FAIRBORN
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State | OH
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Zip | 45324
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Country | US
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Telephone | 937-245-7100
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Fax | 937-245-7999
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301102150
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License Number State | MI
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