Provider Demographics
NPI:1053467357
Name:RADZIK, JAN (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:RADZIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 SE BAKER ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6039
Mailing Address - Country:US
Mailing Address - Phone:503-472-9438
Mailing Address - Fax:503-472-9439
Practice Address - Street 1:349 SE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6039
Practice Address - Country:US
Practice Address - Phone:503-472-9438
Practice Address - Fax:503-472-9439
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 17050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029186Medicaid
ORC46223Medicare UPIN
OR107435Medicare ID - Type Unspecified