Provider Demographics
NPI:1871568204
Name:PRADKO, JACQUELINE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANN
Last Name:PRADKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32740 23 MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1978
Mailing Address - Country:US
Mailing Address - Phone:586-725-7686
Mailing Address - Fax:586-725-7303
Practice Address - Street 1:32740 23 MILE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-1978
Practice Address - Country:US
Practice Address - Phone:586-725-7686
Practice Address - Fax:586-725-7303
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M85280Medicare ID - Type Unspecified
MIMI5339001Medicare PIN
H00174Medicare UPIN