Provider Demographics
NPI:1992772768
Name:REYNOLDS, RICHARD DALE (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DALE
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W HAUGE
Mailing Address - Street 2:STE 120
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902
Mailing Address - Country:US
Mailing Address - Phone:915-532-6662
Mailing Address - Fax:915-532-6686
Practice Address - Street 1:125 W HAUGE
Practice Address - Street 2:STE 120
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-532-6662
Practice Address - Fax:915-532-6686
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK78752086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M0830OtherBLUE CROSS
TX8M0830OtherBLUE CROSS
H06498Medicare UPIN