Provider Demographics
NPI:1760480461
Name:RAEDER, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RAEDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18653 WEDGE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3323
Mailing Address - Country:US
Mailing Address - Phone:775-352-7201
Mailing Address - Fax:
Practice Address - Street 1:18653 WEDGE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-3323
Practice Address - Country:US
Practice Address - Phone:775-352-7201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510794Medicaid
CAE38640Medicare UPIN