Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 5478 | CO |
NPI | 1619010808 |
---|---|
Provider Name | Dr. Byron Jay Raitz |
First Address | Colorado Springs, CO 80918 |
Second Address | Colorado Springs, CO 80918-6980 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 27/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
660651 | ACN GROUP (01) | CO |