Provider Demographics
NPI:1407068521
Name:REDDY, JOHN JR (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:REDDY
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 PARK MANOR CT
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-4335
Mailing Address - Country:US
Mailing Address - Phone:817-545-2652
Mailing Address - Fax:
Practice Address - Street 1:1428 W PIPELINE RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-4629
Practice Address - Country:US
Practice Address - Phone:817-589-1100
Practice Address - Fax:817-589-1811
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT15461Medicare UPIN
TX8G1908Medicare ID - Type Unspecified