Provider Demographics
NPI:1801847017
Name:RADDATZ, MAUREEN (OD)
Entity Type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:
Last Name:RADDATZ
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 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:5 EYE CENTER DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-3334
Practice Address - Country:US
Practice Address - Phone:618-252-5377
Practice Address - Fax:618-252-3028
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009543152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0814870003OtherMEDICARE NSC NUMBER
237034OtherHARMONY HEALTH PLAN
ILP00053904OtherMEDICARE RAILROAD
IL0814870030OtherMEDICARE NSC NUMBER
IL9543OtherEYEMED
IL046009543Medicaid
IL0814870023OtherMEDICARE NSC NUMBER
IL0814870011OtherMEDICARE NSC NUMBER
085495OtherHEALTH ALLIANCE
ILK00073Medicare PIN
IL0814870003OtherMEDICARE NSC NUMBER