Provider Demographics
NPI:1750966420
Name:RATAJOVA, MIRKA
Entity type:Individual
Prefix:MS
First Name:MIRKA
Middle Name:
Last Name:RATAJOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 LAROACHE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406
Mailing Address - Country:US
Mailing Address - Phone:912-354-8225
Mailing Address - Fax:
Practice Address - Street 1:1 STATION TRL
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-3141
Practice Address - Country:US
Practice Address - Phone:912-927-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003015225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA037755764OtherGA DRIVERS LICENSE