Provider Demographics
NPI:1679667430
Name:RADACK, JEFFREY M (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:RADACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8135 FOREST LN # 515057
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8951 COLLIN MCKINNEY PKWY
Practice Address - Street 2:STE 603
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-8294
Practice Address - Country:US
Practice Address - Phone:469-742-0406
Practice Address - Fax:469-952-2806
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1617213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P1650OtherBC/BS
TX157502902Medicaid
TXDP1617OtherWORK COMP
TX752825783OtherTAX ID NUMBER
TX8P1650OtherBC/BS
TXU92764Medicare UPIN
TX8B7712Medicare ID - Type Unspecified