Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | ME0026868 | FL |
NPI | 1417955840 |
---|---|
Provider Name | Dr. Raul A Correa |
First Address | Bradenton, FL 34210-4113 |
Second Address | Bradenton, FL 34205-4935 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D56552 | (02) |