Provider Demographics
NPI:1740254069
Name:GAEDTKE, DORIT DORCAS (MD)
Entity type:Individual
Prefix:
First Name:DORIT
Middle Name:DORCAS
Last Name:GAEDTKE
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 1:1927 SARANAC AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-1112
Mailing Address - Country:US
Mailing Address - Phone:518-523-7575
Mailing Address - Fax:518-523-7577
Practice Address - Street 1:1927 SARANAC AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-1112
Practice Address - Country:US
Practice Address - Phone:518-523-7575
Practice Address - Fax:518-523-7577
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191687207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01410195Medicaid
NY01410195Medicaid
NY01410195Medicaid