Healthcare Provider Details

I. General information

NPI: 1023047297
Provider Name (Legal Business Name): RAPHAEL ALEXANDER RUSYNYK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MACK BAYOU LOOP STE 101
SANTA ROSA BEACH FL
32459-7194
US

IV. Provider business mailing address

417A RACETRACK RD NW STE 2
FORT WALTON BEACH FL
32547-4604
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-5990
  • Fax: 850-862-0041
Mailing address:
  • Phone: 850-863-5990
  • Fax: 850-862-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS8902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: