Provider Demographics
NPI:1629104146
Name:RONALD J. REARDON, M.D., P.A.
Entity Type:Organization
Organization Name:RONALD J. REARDON, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-403-3490
Mailing Address - Street 1:PO BOX 690868
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78269-0868
Mailing Address - Country:US
Mailing Address - Phone:210-403-3490
Mailing Address - Fax:210-403-2042
Practice Address - Street 1:540 MADISON OAK DR
Practice Address - Street 2:SUITE 340
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3921
Practice Address - Country:US
Practice Address - Phone:210-403-3490
Practice Address - Fax:210-403-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0107PUOtherBCBS
TX00769LOtherMEDICARE PTAN
TXDR5045OtherRAILROAD MEDICARE PROVIDER NUMBER