Healthcare Provider Details

I. General information

NPI: 1710967682
Provider Name (Legal Business Name): NICHOLAS A. RADETZKY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3582 BROADWAY
NEW YORK NY
10031-3201
US

IV. Provider business mailing address

3582 BROADWAY
NEW YORK NY
10031-3201
US

V. Phone/Fax

Practice location:
  • Phone: 212-234-2020
  • Fax: 212-234-4609
Mailing address:
  • Phone: 212-234-2020
  • Fax: 212-234-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number4372
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: