Provider Demographics
NPI:1578643367
Name:REARDON, TERRY F (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:F
Last Name:REARDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:512 SAYBROOK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4788
Mailing Address - Country:US
Mailing Address - Phone:860-347-7636
Mailing Address - Fax:860-894-1882
Practice Address - Street 1:512 SAYBROOK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4788
Practice Address - Country:US
Practice Address - Phone:860-347-7636
Practice Address - Fax:860-894-1882
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033671207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001336719Medicaid
CT200000828Medicare ID - Type Unspecified
CT001336719Medicaid