Provider Demographics
NPI:1215138011
Name:RADTKE, JAY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:MICHAEL
Last Name:RADTKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-1924
Mailing Address - Country:US
Mailing Address - Phone:850-747-5740
Mailing Address - Fax:
Practice Address - Street 1:3737 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-1924
Practice Address - Country:US
Practice Address - Phone:850-747-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107594207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology