Provider Demographics
NPI:1114239092
Name:RADKOWIEC, JILL DENISE SMITH (OD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:DENISE SMITH
Last Name:RADKOWIEC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:DENISE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018
Mailing Address - Country:US
Mailing Address - Phone:573-796-2222
Mailing Address - Fax:573-796-4184
Practice Address - Street 1:202 E NORTH STREET
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018
Practice Address - Country:US
Practice Address - Phone:573-796-2222
Practice Address - Fax:573-796-4184
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020657152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist