Provider Demographics
NPI:1477098861
Name:RADOVICH, MARY (MS RD CD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RADOVICH
Suffix:
Gender:F
Credentials:MS RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E DOVER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2003
Mailing Address - Country:US
Mailing Address - Phone:773-706-7447
Mailing Address - Fax:
Practice Address - Street 1:303 E DOVER ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-2003
Practice Address - Country:US
Practice Address - Phone:773-706-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2605-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered