Provider Demographics
NPI:1306819560
Name:RADKE, MATTHEW LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEE
Last Name:RADKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 3RD AVE
Mailing Address - Street 2:PO BOX 100
Mailing Address - City:SHELDON
Mailing Address - State:IA
Mailing Address - Zip Code:51201-0100
Mailing Address - Country:US
Mailing Address - Phone:712-324-2552
Mailing Address - Fax:712-324-2553
Practice Address - Street 1:928 3RD AVE
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-0100
Practice Address - Country:US
Practice Address - Phone:712-324-2552
Practice Address - Fax:712-324-2553
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1145197OtherMEDICAID INDV PAULLINA
IA56024OtherWELLMARK INDV SHELDON
IAI7585OtherMEDICARE GROUP PAULLINA
IA56025OtherMEDICARE INDV PAULLINA
IACS7580OtherRR MEDICARE-GROUP SHELDON
IAI7584OtherMEDICARE GROUP SHELDON
IA56025OtherWELLMARK INDV PAULLINA
IA0145177Medicaid
IA0280578OtherMEDICAID GROUP PAULLINA
IA0280586OtherMEDICAID GROUP SHELDON
IA33340OtherWELLMARK GROUP PAULLINA
IA33330OtherWELLMARK GROUP SHELDON
IACE1831OtherRR MEDICARE-GROUP PAULLIN
IA56024Medicare ID - Type Unspecified
IA0145177Medicaid
IA1145197OtherMEDICAID INDV PAULLINA
IA56025OtherWELLMARK INDV PAULLINA