Provider Demographics
NPI:1699857003
Name:RAEDER, RENATA B (OD)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:B
Last Name:RAEDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 D CORNWALL STREET NW
Mailing Address - Street 2:STE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:21475 RIDGETOP CIRCLE SUITE 300
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-8580
Practice Address - Country:US
Practice Address - Phone:703-430-4400
Practice Address - Fax:703-430-4130
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000741152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699857003Medicaid
MD1651005-03Medicaid
VA30015392870001Medicaid
MD1651005-01Medicaid
MD1651005-00Medicaid
MD1651005-02Medicaid
VA335313OtherANTHEM BCBS/HEALTHKEEPERS
MD1651005-01Medicaid
VA9234161Medicaid
MD1651005-00Medicaid
VA335311OtherANTHEM BCBS/HEALTHKEEPERS
VA9234187Medicaid
VA335314OtherANTHEM BCBS/HEALTHKEEPERS
VA410001088Medicaid
VI9234179Medicaid
VA002255N63Medicare ID - Type UnspecifiedTRAILBLAZERS NVA, DEL, MD