Provider Demographics
NPI:1457494080
Name:RADLOFF, JOHN DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:RADLOFF
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 CHAMPA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2529
Mailing Address - Country:US
Mailing Address - Phone:303-312-2217
Mailing Address - Fax:303-293-2309
Practice Address - Street 1:2130 STOUT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2827
Practice Address - Country:US
Practice Address - Phone:303-293-2220
Practice Address - Fax:303-296-8826
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1845363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38804743Medicaid
CO302011Medicare PIN