Healthcare Provider Details

I. General information

NPI: 1790744746
Provider Name (Legal Business Name): PAUL A RASKAUSKAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 INTERNATIONAL CENTER BLVD
FT MYERS FL
33912-7125
US

IV. Provider business mailing address

6901 INTERNATIONAL CENTER BLVD
FORT MYERS FL
33912-7125
US

V. Phone/Fax

Practice location:
  • Phone: 239-939-4323
  • Fax: 239-939-3983
Mailing address:
  • Phone: 239-939-4323
  • Fax: 239-939-3983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME0060400
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberME0060400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: