Provider Demographics
NPI:1659723310
Name:RADTKE, THERESA (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:RADTKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-2120
Mailing Address - Country:US
Mailing Address - Phone:973-594-0020
Mailing Address - Fax:973-594-0120
Practice Address - Street 1:1053 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-2120
Practice Address - Country:US
Practice Address - Phone:973-594-0020
Practice Address - Fax:973-594-0120
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008483152W00000X
NJ270A00667600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist