Provider Demographics
NPI:1255541959
Name:R D & J MEDICAL PA
Entity type:Organization
Organization Name:R D & J MEDICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:KOLECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-540-1495
Mailing Address - Street 1:1708 CAPE CORAL PKWY W
Mailing Address - Street 2:SUITE H
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-6985
Mailing Address - Country:US
Mailing Address - Phone:239-540-1495
Mailing Address - Fax:239-549-1080
Practice Address - Street 1:1708 CAPE CORAL PKWY W
Practice Address - Street 2:SUITE H
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6985
Practice Address - Country:US
Practice Address - Phone:239-540-1495
Practice Address - Fax:239-549-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4227Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER