Provider Demographics
NPI:1982831624
Name:REARDON, RYAN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:REARDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-877-3280
Practice Address - Street 1:801 W. TERRELL AVE.
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3100
Practice Address - Country:US
Practice Address - Phone:817-877-3277
Practice Address - Fax:817-877-3280
Is Sole Proprietor?:No
Enumeration Date:2009-06-21
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6607207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00850287OtherRAILROAD MEDICARE
TX214299401Medicaid