Provider Demographics
NPI:1336145440
Name:RADICK, JASON L (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:RADICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 ALTON RD, GREEN BLDG
Mailing Address - Street 2:STE 810
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2800
Mailing Address - Country:US
Mailing Address - Phone:305-674-5925
Mailing Address - Fax:305-674-5927
Practice Address - Street 1:4300 ALTON RD, GREEN BLDG
Practice Address - Street 2:STE 810
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2800
Practice Address - Country:US
Practice Address - Phone:305-674-5925
Practice Address - Fax:305-674-5927
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82103207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265949200Medicaid
FLE7499ZMedicare PIN
FL265949200Medicaid