Provider Demographics
NPI:1285868968
Name:REYNOLDS, ROBERT RAY (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RAY
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 1:500 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4445
Mailing Address - Country:US
Mailing Address - Phone:701-222-6100
Mailing Address - Fax:701-222-6150
Practice Address - Street 1:500 N 8TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-222-6100
Practice Address - Fax:701-222-6150
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD.32576LL2085R0001X
MO20140346632085R0001X
ND144042085R0001X
TXBP10034767207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1469785Medicaid