Healthcare Provider Details

I. General information

NPI: 1972950285
Provider Name (Legal Business Name): KARA TRAPP REARDON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 REDSTONE AVE W
CRESTVIEW FL
32536-6433
US

IV. Provider business mailing address

350 REDSTONE AVE W
CRESTVIEW FL
32536-6433
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-1740
  • Fax: 850-682-6652
Mailing address:
  • Phone: 850-689-1740
  • Fax: 850-682-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLP03604
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME133359
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME133359
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: