Provider Demographics
NPI:1053319335
Name:RADISH, DOUGLAS E (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:RADISH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:65 CABELLO ST
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-5206
Mailing Address - Country:US
Mailing Address - Phone:941-255-5776
Mailing Address - Fax:941-255-9105
Practice Address - Street 1:24420 SANDHILL BLVD
Practice Address - Street 2:UNIT 101
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-5272
Practice Address - Country:US
Practice Address - Phone:941-255-5776
Practice Address - Fax:941-255-9105
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78421400Medicaid
FL20205SMedicare PIN
T85250Medicare UPIN