Provider Demographics
NPI:1174818454
Name:REDONDO, RAQUEL ELISA (MD)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:ELISA
Last Name:REDONDO
Suffix:
Gender:F
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:9800 VALPARAISO DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4040
Practice Address - Country:US
Practice Address - Phone:219-934-9800
Practice Address - Fax:219-924-8831
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01080526A208600000X
MDD81389208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD109547100Medicaid
MD109547100Medicaid