Provider Demographics
NPI:1114933660
Name:VIDAKOVIC, LYNN (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:VIDAKOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:RADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-7342
Mailing Address - Fax:414-805-7919
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-7342
Practice Address - Fax:414-805-7919
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77097208100000X
IL036-114330208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1114933660Medicaid
IL036114330Medicaid
ILP00259786OtherRAILROAD MEDICARE NUMBER
ILK22349Medicare PIN
ILK22348Medicare PIN
ILK23843Medicare PIN