Provider Demographics
NPI:1639245988
Name:POWELL, REED MADSEN JR (OD)
Entity Type:Individual
Prefix:DR
First Name:REED
Middle Name:MADSEN
Last Name:POWELL
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21660 BEAR VALLEY RD
Mailing Address - Street 2:F-2
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-7226
Mailing Address - Country:US
Mailing Address - Phone:760-961-0344
Mailing Address - Fax:760-961-0344
Practice Address - Street 1:21660 BEAR VALLEY RD
Practice Address - Street 2:F-2
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-7226
Practice Address - Country:US
Practice Address - Phone:760-961-0344
Practice Address - Fax:760-961-0363
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7678T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0076780Medicaid