Provider Demographics
NPI:1649270265
Name:REARDON, PATRICK RAY (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:RAY
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 1:6550 FANNIN ST STE 2435
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2767
Mailing Address - Country:US
Mailing Address - Phone:713-790-3140
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST STE 2435
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-790-3140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5518208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134231308Medicaid
TXP01036906OtherRR MEDICARE
TX8AC476OtherBLUE CROSS BLUE SHIELD
TX8AC476OtherBCBS
TX8DY834OtherBLUE CROSS BLUE SHIELD
TX8G5880OtherBCBS
TXP00442979OtherRAILROAD MEDICARE
TX134231309Medicaid
TX8AC476OtherBLUE CROSS BLUE SHIELD
TX8988B8Medicare PIN
TX8DY834OtherBLUE CROSS BLUE SHIELD
E39482Medicare UPIN
TX134231309Medicaid
TX539479ZSWDMedicare PIN