Provider Demographics
NPI:1265516645
Name:RADKE, LAURA L (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:RADKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N14W23900 STONE RIDGE DR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1135
Mailing Address - Country:US
Mailing Address - Phone:262-574-8000
Mailing Address - Fax:
Practice Address - Street 1:N14W23900 STONE RIDGE DR
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1135
Practice Address - Country:US
Practice Address - Phone:262-574-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31373207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31870200Medicaid
WI31870200Medicaid
68375Medicare PIN