Provider Demographics
NPI:1487086195
Name:REYNOLDS, IAN ALLAN (BOCP)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:ALLAN
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:BOCP
Other - Prefix:
Other - First Name:IAN
Other - Middle Name:ALLAN
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BOCP
Mailing Address - Street 1:796 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3921
Mailing Address - Country:US
Mailing Address - Phone:510-335-5068
Mailing Address - Fax:
Practice Address - Street 1:463 BREWSTER AVE
Practice Address - Street 2:#6
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1785
Practice Address - Country:US
Practice Address - Phone:650-368-9597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTC51219OtherBOC CERTIFICATION NUMBER