Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | WV14661 | WV |
NPI | 1043277270 |
---|---|
Provider Name | Dr. Harry Richard Reynolds |
First Address | Charleston, WV 25304-1062 |
Second Address | Charleston, WV 25304-1062 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2006 |
Last Update Date | 25/01/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0069872000 | (05) | WV |
51D0234293 | CLIA (01) | WV |
55-0672861 | TAX ID (01) | WV |
B42697 | (02) | WV |
BRO446383 | DEA (01) | WV |
WV14661 | WV LICENSE (01) | WV |