Provider Demographics
NPI:1871572651
Name:REARDON, DAVID M (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
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 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:1620 MEDICAL LN
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1143
Practice Address - Country:US
Practice Address - Phone:239-275-1164
Practice Address - Fax:239-275-5212
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50460207ZP0102X, 207ZB0001X, 207ZP0104X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No207ZP0104XAllopathic & Osteopathic PhysiciansPathologyChemical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374108700Medicaid
FL08172YMedicare PIN
FL374108700Medicaid