Healthcare Provider Details

I. General information

NPI: 1043222334
Provider Name (Legal Business Name): JAMES D. RAQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 NORTH STREET
WATERVILLE ME
04901-4974
US

IV. Provider business mailing address

PO BOX 766
WATERVILLE ME
04901-0766
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-0729
  • Fax: 207-873-4338
Mailing address:
  • Phone: 207-873-0729
  • Fax: 207-873-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number017660
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number42012
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number017660
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: