Healthcare Provider Details

I. General information

NPI: 1730838533
Provider Name (Legal Business Name): DEEP RAOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12 AVENUE
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-4310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME165447
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: