Provider Demographics
NPI:1629508825
Name:RADICH, DEREK A (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:A
Last Name:RADICH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WESTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-7231
Mailing Address - Country:US
Mailing Address - Phone:845-913-6953
Mailing Address - Fax:
Practice Address - Street 1:1 HATFIELD LN STE 3
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6753
Practice Address - Country:US
Practice Address - Phone:845-294-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist