Basic Information
| Provider Information | |||||||||
| NPI: | 1801858188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REARDON | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 RODGERS DR | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012797979 | ||||||||
| FaxNumber: | 5013053535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 03/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01052011A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-6132 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 178688001 | 05 | AR | MEDICAID |