Provider Demographics
NPI:1285768796
Name:RADKE, MARCIA A (MD)
Entity type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:A
Last Name:RADKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MARCIA
Other - Middle Name:ANN
Other - Last Name:DOLVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3251 N MCMULLEN BOOTH RD STE 104
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2022
Mailing Address - Country:US
Mailing Address - Phone:727-799-0415
Mailing Address - Fax:813-635-7941
Practice Address - Street 1:3251 N MCMULLEN BOOTH RD STE 104
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2022
Practice Address - Country:US
Practice Address - Phone:727-799-0415
Practice Address - Fax:813-635-7941
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50538207R00000X
OH57.009005207R00000X
FLME114268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009925400Medicaid
WI34795700Medicaid
WI02525Medicare PIN
WI34795700Medicaid
FLP01478879Medicare PIN