Provider Demographics
NPI:1427058262
Name:REYNOLDS, TERRY (OD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207243
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7243
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:7 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARAB
Practice Address - State:AL
Practice Address - Zip Code:35016-1977
Practice Address - Country:US
Practice Address - Phone:256-586-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS437-TA119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059586Medicaid
AL1427058262OtherMEDICARE NPI
ALT69038Medicare UPIN
AL000059586Medicaid