Provider Demographics
NPI:1619976230
Name:VRDOLJAK, JAKE (MD)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:VRDOLJAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VATROSLAV
Other - Middle Name:
Other - Last Name:VRDOLJAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:17310 WRIGHT ST
Mailing Address - Street 2:STE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2405
Mailing Address - Country:US
Mailing Address - Phone:833-228-6889
Mailing Address - Fax:877-853-0376
Practice Address - Street 1:8926 WOODYARD RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:301-856-3670
Practice Address - Fax:301-868-0129
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2857212085R0202X
DCMD319142085R0202X
MO20200363062085R0202X
WY13076C2085R0202X
ND168812085R0202X
MDD00538522085R0202X
IL0360956232085R0205X
VA01012221802085R0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC023794900Medicaid
MD510908600Medicaid
VA1619976230Medicaid
VAVV9873AMedicare PIN
DC008253M31Medicare PIN
VA1619976230Medicaid
DCP01254258Medicare PIN
H49571Medicare UPIN
MDP01208228Medicare PIN