Basic Information
| Provider Information | |||||||||
| NPI: | 1861465635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAYNOR | ||||||||
| FirstName: | REGINALD | ||||||||
| MiddleName: | WINFIELD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 HAYNES ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606468888 | ||||||||
| FaxNumber: | 8606468885 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 HAYNES ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606468888 | ||||||||
| FaxNumber: | 8606468885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 03/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 26317 | CT | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001263177 | 05 | CT | MEDICAID |