Healthcare Provider Details

I. General information

NPI: 1053371773
Provider Name (Legal Business Name): CAROLYN L RAIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BARD AVE
STATEN ISLAND NY
10310-1666
US

IV. Provider business mailing address

360 BARD AVE
STATEN ISLAND NY
10310-1666
US

V. Phone/Fax

Practice location:
  • Phone: 718-876-2000
  • Fax: 718-876-2006
Mailing address:
  • Phone: 718-876-2000
  • Fax: 718-876-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number183266
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: