Provider Demographics
NPI:1487607057
Name:REARDON, MICHAEL S (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:REARDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 WELCH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1805
Mailing Address - Country:US
Mailing Address - Phone:650-617-8655
Mailing Address - Fax:650-322-3416
Practice Address - Street 1:900 WELCH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1805
Practice Address - Country:US
Practice Address - Phone:650-617-8655
Practice Address - Fax:650-322-3416
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA305752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0012480Medicaid
CA00A305750Medicare PIN
CAA30575Medicare UPIN