Provider Demographics
NPI:1114178340
Name:DEAN L RACKLEFF MD PA
Entity Type:Organization
Organization Name:DEAN L RACKLEFF MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:RACKLEFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-455-9946
Mailing Address - Street 1:9400 BONITA BEACH ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135
Mailing Address - Country:US
Mailing Address - Phone:239-455-9946
Mailing Address - Fax:239-455-9947
Practice Address - Street 1:9400 BONITA BEACH RD SE STE 102
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4520
Practice Address - Country:US
Practice Address - Phone:239-455-9946
Practice Address - Fax:239-455-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069187207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378687100Medicaid
FL76425Medicare UPIN