Provider Demographics
NPI:1982601001
Name:REYNOLDS, KIRSTEN KLAUSS (OD)
Entity type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:KLAUSS
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1425
Mailing Address - Country:US
Mailing Address - Phone:618-233-1270
Mailing Address - Fax:618-233-5939
Practice Address - Street 1:22 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1425
Practice Address - Country:US
Practice Address - Phone:618-233-1270
Practice Address - Fax:618-233-5939
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211358OtherMEDICARE GROUP NUMBER
5426840001Medicare NSC
IL211358OtherMEDICARE GROUP NUMBER
ILK16140Medicare PIN