Basic Information
| Provider Information | |||||||||
| NPI: | 1902886443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDER | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N 15TH ST | ||||||||
| Address2: | |||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751104514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032294141 | ||||||||
| FaxNumber: | 9038725273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6616TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1752503 | 05 | TX | MEDICAID |