Active NPI
Owen David Reynolds, M.D.
- Dermatology Physician
- North Andover, MA
National Provider Identifier
1407845712
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- License
- 74177
- Practice address
- 198 Massachusetts Ave Ste 105
North Andover, MA 01845-4143 - Phone
- (978) 691-5690
- Fax
- (978) 691-5693
- NPI assigned
- Oct 19, 2005
- Last updated
- Dec 3, 2018
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | 74177 | MA | Primary |
| Procedural Dermatology Physician | 207NS0135X | 74177 | MA |
Addresses
Primary practice location
198 Massachusetts Ave Ste 105
North Andover, MA 01845-4143
Mailing address
280 Merrimack St Ste 311
Lawrence, MA 01843-1779
Phone (978) 691-5690
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3102769 | Medicaid | MA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20041005000539 | MA | Practitioner - Dermatology | 1951360296 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Nedab LLC | Dermatology | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1129680000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1543795200000",
"number": "1407845712",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "280 MERRIMACK ST STE 311",
"city": "LAWRENCE",
"state": "MA",
"postal_code": "018431779",
"telephone_number": "978-691-5690",
"fax_number": "978-691-5693"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "198 MASSACHUSETTS AVE STE 105",
"city": "NORTH ANDOVER",
"state": "MA",
"postal_code": "018454143",
"telephone_number": "978-691-5690",
"fax_number": "978-691-5693"
}
],
"practiceLocations": [],
"basic": {
"last_name": "REYNOLDS",
"first_name": "OWEN",
"middle_name": "DAVID",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-10-19",
"last_updated": "2018-12-03",
"status": "A"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "",
"desc": "Dermatology",
"state": "MA",
"license": "74177",
"primary": true
},
{
"code": "207NS0135X",
"taxonomy_group": "",
"desc": "Dermatology, Procedural Dermatology",
"state": "MA",
"license": "74177",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "3102769",
"state": "MA"
}
],
"endpoints": [],
"other_names": []
}Other providers in North Andover, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.