Provider Demographics
NPI:1336171776
Name:O REARDON, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:O 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 1:2301 E EVESHAM RD STE 304
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4503
Mailing Address - Country:US
Mailing Address - Phone:856-375-2406
Mailing Address - Fax:856-888-1390
Practice Address - Street 1:2301 E EVESHAM RD STE 304
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4503
Practice Address - Country:US
Practice Address - Phone:856-375-2406
Practice Address - Fax:856-888-1390
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059532L2084N0400X
NJ25MA061372002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6518702Medicaid
PA0016729000001Medicaid
PA0016729000001Medicaid
G07287Medicare UPIN
PA016176Medicare PIN