Provider Demographics
NPI:1831305861
Name:RADLER, WILFRED J (MD)
Entity Type:Individual
Prefix:
First Name:WILFRED
Middle Name:J
Last Name:RADLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5653 HIGHWAY 95
Mailing Address - Street 2:STE A
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6069
Mailing Address - Country:US
Mailing Address - Phone:928-768-2558
Mailing Address - Fax:928-768-2874
Practice Address - Street 1:4263 HIGHWAY 68
Practice Address - Street 2:STE C
Practice Address - City:GOLDEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86413-8569
Practice Address - Country:US
Practice Address - Phone:928-565-3939
Practice Address - Fax:928-565-4111
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2014-08-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ8288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ206707Medicaid
D00148Medicare UPIN