Provider Demographics
NPI:1699713784
Name:REYNOLDS, SARA JEAN (MD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JEAN
Last Name: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 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5004
Mailing Address - Country:US
Mailing Address - Phone:802-447-5648
Mailing Address - Fax:802-447-5609
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201
Practice Address - Country:US
Practice Address - Phone:802-447-5648
Practice Address - Fax:802-447-5609
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-0008018207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01342901Medicaid
VT1003556Medicaid
VT5082448OtherAETNA
VT042.0008018OtherLICENSE
VT2112406OtherVERMONT BLUE CROSS BLUE S
11415OtherMOHAWK VALLEY HEALTH PLAN
VT1003556Medicaid