Provider Demographics
NPI:1043383938
Name:RAYDER, ROBERT EDWARD
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:RAYDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 EVANS AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9385
Mailing Address - Country:US
Mailing Address - Phone:239-278-9983
Mailing Address - Fax:239-278-9985
Practice Address - Street 1:4048 EVANS AVE STE 209
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9385
Practice Address - Country:US
Practice Address - Phone:239-278-9983
Practice Address - Fax:239-278-9985
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371731300Medicaid