Provider Demographics
NPI:1871521567
Name:REDER, PAUL A (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:REDER
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 1:1620 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1008
Mailing Address - Country:US
Mailing Address - Phone:801-822-2234
Mailing Address - Fax:
Practice Address - Street 1:34910 INTERSTATE 10 W
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-9229
Practice Address - Country:US
Practice Address - Phone:361-994-4880
Practice Address - Fax:361-994-4890
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101249207Y00000X
TXJ7153207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100262986Medicaid
TX1353229-12Medicaid
TX135322913Medicaid
TX8BR082OtherBCBS
TX8S4592OtherBCBS
TX135322914Medicaid
TX135322916Medicaid
TX8BR082OtherBCBS
TXE57966Medicare UPIN
TX135322914Medicaid
TX8L5636Medicare PIN
TX8L19406Medicare PIN
TX488799YMJMMedicare PIN