Provider Demographics
NPI:1104801265
Name:REAGIN, RONALD S SR (DPM)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:S
Last Name:REAGIN
Suffix:SR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:656 A-B S MAIN ST
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31515-0708
Mailing Address - Country:US
Mailing Address - Phone:912-367-5281
Mailing Address - Fax:912-367-5240
Practice Address - Street 1:656 A-B S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31515
Practice Address - Country:US
Practice Address - Phone:912-367-5281
Practice Address - Fax:912-367-5240
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000613213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA48SCBCSOtherMEDICARE ID TYPE PODIATRY
GA000415346AMedicaid
GA480007952OtherRAILROAD MEDICARE
GA48SCBCSMedicare PIN
GA48SCBCSOtherMEDICARE ID TYPE PODIATRY
GA0753530001Medicare NSC