Provider Demographics
NPI:1588054324
Name:PATRICK L REARDON OD
Entity type:Organization
Organization Name:PATRICK L REARDON OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-743-9955
Mailing Address - Street 1:961 CESERY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5678
Mailing Address - Country:US
Mailing Address - Phone:904-743-9955
Mailing Address - Fax:904-743-2802
Practice Address - Street 1:961 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5678
Practice Address - Country:US
Practice Address - Phone:904-743-9955
Practice Address - Fax:904-743-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114979OtherEYEMED
FL19736OtherFLORIDA BLUE
FL078642000Medicaid
FL19736OtherFLORIDA BLUE
FL078642000Medicaid
FL410007720Medicare PIN