Provider Demographics
NPI:1316099153
Name:REYNOLDS, RICKEY J (MD PHD)
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:J
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 ANDREWS HWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-4817
Mailing Address - Country:US
Mailing Address - Phone:432-686-6605
Mailing Address - Fax:432-682-2284
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY STE 120
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5849
Practice Address - Country:US
Practice Address - Phone:432-221-3700
Practice Address - Fax:432-685-0834
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN477622084N0400X
TXJ44742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1316099153Medicaid
MN110523000Medicaid
TX203416702Medicaid
TX8TL498OtherBCBS TX
TX8W6745OtherBCBS
TX752616977052OtherTRICARE
G37638Medicare UPIN
TX203416702Medicaid