Provider Demographics
NPI:1982828703
Name:REDUS, MICHAEL J (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:REDUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:J
Other - Last Name:REDUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1001 OVER MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2855
Mailing Address - Country:US
Mailing Address - Phone:423-543-3293
Mailing Address - Fax:423-543-8305
Practice Address - Street 1:1001 OVER MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2855
Practice Address - Country:US
Practice Address - Phone:423-543-3293
Practice Address - Fax:423-543-8305
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5314T152W00000X
TN1731152W00000X
GAOPT001566152W00000X
ALR-192-TA-861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU66363Medicare UPIN