Provider Demographics
NPI:1154416006
Name:REYNOLDS, WILLIAM ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 E BRADFORD PKWY STE 215
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6539
Mailing Address - Country:US
Mailing Address - Phone:417-823-9777
Mailing Address - Fax:417-823-9731
Practice Address - Street 1:1531 E BRADFORD PKWY STE 215
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6539
Practice Address - Country:US
Practice Address - Phone:417-894-1079
Practice Address - Fax:417-823-9731
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107745174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154416006Medicaid
MO1336300466Medicaid
MO1154416006Medicaid
MO001014637Medicare PIN