Healthcare Provider Details

I. General information

NPI: 1447580022
Provider Name (Legal Business Name): RAYMOND WILLIAM PRYOR III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 SW 160TH AVE SUITE #250
MIRAMAR FL
33027-6308
US

IV. Provider business mailing address

3601 SW 160TH AVE SUITE #250
MIRAMAR FL
33027-6308
US

V. Phone/Fax

Practice location:
  • Phone: 954-399-4642
  • Fax: 877-859-8768
Mailing address:
  • Phone: 954-399-4642
  • Fax: 877-859-8768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036124770
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036124770
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036124770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: