Provider Demographics
NPI:1043222334
Name:RAQUE, JAMES D (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:RAQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-0766
Mailing Address - Country:US
Mailing Address - Phone:207-873-0729
Mailing Address - Fax:207-873-4338
Practice Address - Street 1:149 NORTH STREET
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-873-0729
Practice Address - Fax:207-873-4338
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO420122085R0204X
ME0176602085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50973550Medicaid
ME1043222334Medicaid
COC803975Medicare PIN
COP00130982Medicare PIN
COCO301472Medicare PIN
COC801369Medicare PIN
COC801370Medicare PIN
COC511868Medicare PIN
ME000391601Medicare PIN
COH14557Medicare UPIN
COC809549Medicare PIN
COC810970Medicare PIN