Provider Demographics
NPI:1396837753
Name:RADAS, JERRY LEE (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:RADAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 MAPLE LAWN BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2565
Mailing Address - Country:US
Mailing Address - Phone:301-490-8550
Mailing Address - Fax:301-490-8581
Practice Address - Street 1:7625 MAPLE LAWN BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2565
Practice Address - Country:US
Practice Address - Phone:301-490-8550
Practice Address - Fax:301-490-8581
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSO1592111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM123JLOtherCAREFIRST BCBS
W3530001OtherCAREFIRST BCBS
W3530001OtherCAREFIRST BCBS