Provider Demographics
NPI:1417041070
Name:REIDY, JOHN F (OD, PS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:F
Last Name:REIDY
Suffix:
Gender:M
Credentials:OD, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 E SPRAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99212-0826
Mailing Address - Country:US
Mailing Address - Phone:509-842-0001
Mailing Address - Fax:509-842-0013
Practice Address - Street 1:5601 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99212-0826
Practice Address - Country:US
Practice Address - Phone:509-842-0001
Practice Address - Fax:509-842-0013
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8805615OtherMEDICARE GROUP PIN
WAT02453Medicare UPIN
WA8805617Medicare PIN