Healthcare Provider Details

I. General information

NPI: 1548278245
Provider Name (Legal Business Name): JAMES L RADERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 MALABAR RD NE STE 245
MELBOURNE FL
32907-2586
US

IV. Provider business mailing address

3300 S FISKE BLVD
MELBOURNE FL
32901-1966
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-8210
  • Fax: 321-434-8211
Mailing address:
  • Phone: 321-434-8210
  • Fax: 321-434-8211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number29481
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME111294
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberME111294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: