Provider Demographics
NPI:1437327053
Name:RADKE, JAN RODGER (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:RODGER
Last Name:RADKE
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 1:13241 LUCKETT CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13241 LUCKETT CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3225
Practice Address - Country:US
Practice Address - Phone:858-259-1239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-16
Last Update Date:2008-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85793207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB48169Medicare UPIN