Provider Demographics
NPI:1174364178
Name:MAGDAONG, SIDNEY ALDRIAN REYNES (OD)
Entity type:Individual
Prefix:DR
First Name:SIDNEY ALDRIAN
Middle Name:REYNES
Last Name:MAGDAONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:SIDNEY
Other - Middle Name:
Other - Last Name:MAGDAONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 7062
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7062
Mailing Address - Country:US
Mailing Address - Phone:812-855-8436
Mailing Address - Fax:
Practice Address - Street 1:744 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3603
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004493A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist