Basic Information
| Provider Information | |||||||||
| NPI: | 1619976230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VRDOLJAK | ||||||||
| FirstName: | JAKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VRDOLJAK | ||||||||
| OtherFirstName: | VATROSLAV | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17310 WRIGHT ST | ||||||||
| Address2: | STE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8332286889 | ||||||||
| FaxNumber: | 8778530376 | ||||||||
| Practice Location | |||||||||
| Address1: | 8926 WOODYARD RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018563670 | ||||||||
| FaxNumber: | 3018680129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 16881 | ND | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD31914 | DC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 285721 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | D0053852 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0205X | 0101222180 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiological Physics |
ID Information
| ID | Type | State | Issuer | Description | 023794900 | 05 | DC | MEDICAID | 1619976230 | 05 | VA | MEDICAID | 510908600 | 05 | MD | MEDICAID |