1306819560 NPI number — DR. MATTHEW LEE RADKE O.D.

Table of content: DR. MATTHEW LEE RADKE O.D. (NPI 1306819560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306819560 NPI number — DR. MATTHEW LEE RADKE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RADKE
Provider First Name:
MATTHEW
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306819560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
928 3RD AVE
Provider Second Line Business Mailing Address:
PO BOX 100
Provider Business Mailing Address City Name:
SHELDON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51201-0100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-324-2552
Provider Business Mailing Address Fax Number:
712-324-2553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
928 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELDON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51201-0100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-324-2552
Provider Business Practice Location Address Fax Number:
712-324-2553
Provider Enumeration Date:
02/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  02078 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1145197 . This is a "MEDICAID INDV PAULLINA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 56024 . This is a "WELLMARK INDV SHELDON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: I7585 . This is a "MEDICARE GROUP PAULLINA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 56025 . This is a "MEDICARE INDV PAULLINA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: CS7580 . This is a "RR MEDICARE-GROUP SHELDON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: I7584 . This is a "MEDICARE GROUP SHELDON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 56025 . This is a "WELLMARK INDV PAULLINA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0145177 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0280578 . This is a "MEDICAID GROUP PAULLINA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0280586 . This is a "MEDICAID GROUP SHELDON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 33340 . This is a "WELLMARK GROUP PAULLINA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 33330 . This is a "WELLMARK GROUP SHELDON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: CE1831 . This is a "RR MEDICARE-GROUP PAULLIN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com