Provider Demographics
NPI:1619275948
Name:RADU, CORINA ELENA (LMT)
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:ELENA
Last Name:RADU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FAIRWAY PARK BLVD UNIT 1103
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2623
Mailing Address - Country:US
Mailing Address - Phone:904-994-6535
Mailing Address - Fax:904-627-1499
Practice Address - Street 1:1320 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3253
Practice Address - Country:US
Practice Address - Phone:904-627-1494
Practice Address - Fax:904-627-1499
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL55534282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital