Provider Demographics
NPI:1356846273
Name:RADUJKO, PHILIP
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:RADUJKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WATERSIDE PLZ APT 9H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-2630
Mailing Address - Country:US
Mailing Address - Phone:917-582-2286
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-965-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-25
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist