Provider Demographics
NPI:1225179963
Name:RADUAZZO, MICHAEL J SR (BSPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:RADUAZZO
Suffix:SR
Gender:M
Credentials:BSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 COW NECK RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1102
Mailing Address - Country:US
Mailing Address - Phone:516-883-8869
Mailing Address - Fax:
Practice Address - Street 1:196 COW NECK RD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-1102
Practice Address - Country:US
Practice Address - Phone:516-883-8869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0220221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00396745Medicaid
NY00396745Medicaid