Provider Demographics
NPI:1265431357
Name:REARDON, DANIEL B (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:B
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 1:390 TOLL GATE RD
Mailing Address - Street 2:STE.200
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4326
Mailing Address - Country:US
Mailing Address - Phone:401-691-3300
Mailing Address - Fax:401-739-6087
Practice Address - Street 1:390 TOLL GATE RD
Practice Address - Street 2:STE.200
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4326
Practice Address - Country:US
Practice Address - Phone:401-691-3300
Practice Address - Fax:401-739-6087
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI4817208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI003670OtherBLUE CHIP PROVIDER ID
RIDR55188Medicaid
RI29143-3OtherBLUE CROSS PROVIDER ID
RI29143-3OtherBLUE CROSS PROVIDER ID