Healthcare Provider Details

I. General information

NPI: 1417955840
Provider Name (Legal Business Name): RAUL A CORREA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 MANATEE AVE W
BRADENTON FL
34205-4935
US

IV. Provider business mailing address

4004 BAYSIDE DR
BRADENTON FL
34210-4113
US

V. Phone/Fax

Practice location:
  • Phone: 941-748-1171
  • Fax: 941-748-4531
Mailing address:
  • Phone: 941-755-3300
  • Fax: 941-751-3809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberME0026868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: