MEDICARE: ROGER REYNOLDS D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	DO18450	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689682254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER REYNOLDS D.O.

Provider Business Mailing Address
First Line	:	1825 MAPLE ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1939
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 MAPLE ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1939
Country	:	US
Telephone Number	:	503-357-2136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	01/10/2013

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Directions to “ ROGER REYNOLDS D.O.” Practice Location

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