Provider Demographics
NPI:1932136827
Name:RADOSEVICH, MICHAEL DONALD (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DONALD
Last Name:RADOSEVICH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MOUNTAIN LEDGE DR
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:NY
Mailing Address - Zip Code:12831-2539
Mailing Address - Country:US
Mailing Address - Phone:518-437-1111
Mailing Address - Fax:518-435-1114
Practice Address - Street 1:1365 WASHINGTON AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1099
Practice Address - Country:US
Practice Address - Phone:518-437-1111
Practice Address - Fax:518-435-1114
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36488207W00000X
NY252133207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0727685Medicaid
NY03092862Medicaid
IA19934OtherWELLMARK BCBS
NY03092862Medicaid
IA19934OtherWELLMARK BCBS
IA0727685Medicaid
NYBA1415Medicare PIN
IAP00405456Medicare PIN