Provider Demographics
NPI:1831189646
Name:REARDON, PATRICK L (OD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:L
Last Name:REARDON
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 1:961 CESERY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5607
Mailing Address - Country:US
Mailing Address - Phone:904-743-9955
Mailing Address - Fax:904-743-2802
Practice Address - Street 1:961 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5607
Practice Address - Country:US
Practice Address - Phone:904-743-9955
Practice Address - Fax:904-743-2802
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078642000Medicaid
FL19736OtherBLUE CROSS BLUE SHIELD
FL114979OtherEYEMED
FL078642000Medicaid
FL114979OtherEYEMED
FL410007720Medicare PIN