Healthcare Provider Details

I. General information

NPI: 1427048495
Provider Name (Legal Business Name): RAISA D CAMILO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4958 SUN N LAKE BLVD
SEBRING FL
33872-2167
US

IV. Provider business mailing address

4958 SUN N LAKE BLVD
SEBRING FL
33872-2167
US

V. Phone/Fax

Practice location:
  • Phone: 863-385-4711
  • Fax: 863-386-4301
Mailing address:
  • Phone: 863-385-4711
  • Fax: 863-386-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0061030
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: