Provider Demographics
NPI:1083611578
Name:REARDON, JULIE A (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:REARDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 OAKMONT BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734
Mailing Address - Country:US
Mailing Address - Phone:512-850-6963
Mailing Address - Fax:512-309-5437
Practice Address - Street 1:3500 OAKMONT BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6009
Practice Address - Country:US
Practice Address - Phone:512-850-6963
Practice Address - Fax:512-309-5437
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036274207Q00000X
TXP3801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA122707OtherLABOR & IND.
WAAB04842Medicare PIN
WA8277951Medicaid
G42879Medicare UPIN
OR276743Medicaid
WA8921887OtherCRIME VICTIMS