Provider Demographics
NPI:1184682569
Name:RADECKI, RICHARD T (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:RADECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3874 MASTHEAD NE
Mailing Address - Street 2:BLDG G
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4479
Mailing Address - Country:US
Mailing Address - Phone:505-338-2077
Mailing Address - Fax:505-338-1960
Practice Address - Street 1:3874 MASTHEAD NE
Practice Address - Street 2:BLDG G
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4479
Practice Address - Country:US
Practice Address - Phone:505-338-2077
Practice Address - Fax:505-338-1960
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM94364208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00025532Medicaid
E03479Medicare UPIN
NM00025532Medicaid