Provider Demographics
NPI:1710967682
Name:RADETZKY, NICHOLAS A (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:A
Last Name:RADETZKY
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 1:3582 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-3201
Mailing Address - Country:US
Mailing Address - Phone:212-234-2020
Mailing Address - Fax:212-234-4609
Practice Address - Street 1:3582 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-3201
Practice Address - Country:US
Practice Address - Phone:212-234-2020
Practice Address - Fax:212-234-4609
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4372152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01033870Medicaid
NYC32702Medicare PIN
NY01033870Medicaid
NY0323160001Medicare NSC
NYC32701Medicare PIN