Provider Demographics
NPI:1992774855
Name:RADOCHA, RICHARD F (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:F
Last Name:RADOCHA
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 1:635 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4129
Mailing Address - Country:US
Mailing Address - Phone:863-294-0670
Mailing Address - Fax:863-298-3200
Practice Address - Street 1:635 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4129
Practice Address - Country:US
Practice Address - Phone:863-294-0670
Practice Address - Fax:863-298-3200
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37540208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045972100Medicaid
FL110017782OtherMEDICARE ID/ RRM PIN
FL02557ZMedicare PIN
FL045972100Medicaid