Provider Demographics
NPI:1134259021
Name:REEDSTROM, JAMES ALAN (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ALAN
Last Name:REEDSTROM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 TOWER AVENUE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-1504
Mailing Address - Country:US
Mailing Address - Phone:715-394-5722
Mailing Address - Fax:715-394-5729
Practice Address - Street 1:1325 TOWER AVENUE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-1504
Practice Address - Country:US
Practice Address - Phone:715-394-5722
Practice Address - Fax:715-394-5729
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1511035152W00000X
MN1611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1C105OtherMPIN
MN042338600Medicaid
WI38563900Medicaid
WI0285200001Medicare NSC
WI410010934Medicare PIN
WIDO08873Medicare UPIN
MN1C105OtherMPIN
WI38563900Medicaid
MN042338600Medicaid
WI871390001Medicare PIN