Provider Demographics
NPI:1578131884
Name:REARDON, JEFFREY WILLIAM (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:REARDON
Suffix:
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 1:59570 SUNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9683
Mailing Address - Country:US
Mailing Address - Phone:248-912-8774
Mailing Address - Fax:
Practice Address - Street 1:5838 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9619
Practice Address - Country:US
Practice Address - Phone:616-249-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005521152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist