Provider Demographics
NPI:1194784942
Name:CONKLIN REYNOLDS, MARY ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY ANNE
Middle Name:
Last Name:CONKLIN REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2945
Mailing Address - Country:US
Mailing Address - Phone:419-534-3500
Mailing Address - Fax:419-534-2608
Practice Address - Street 1:3170 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2945
Practice Address - Country:US
Practice Address - Phone:419-534-3500
Practice Address - Fax:419-534-2608
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.059840207ZP0102X
MI4301406532207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0805276Medicaid
MI3030916Medicaid
OHMC0680331Medicare ID - Type Unspecified
MI3030916Medicaid
OH0805276Medicaid