Provider Demographics
NPI:1316387947
Name:RAW, ALEXANDER DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DAVID
Last Name:RAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1136
Mailing Address - Country:US
Mailing Address - Phone:217-243-8455
Mailing Address - Fax:217-243-7951
Practice Address - Street 1:1600 W WALNUT ST BLDG 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1136
Practice Address - Country:US
Practice Address - Phone:217-243-8455
Practice Address - Fax:217-243-7951
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-144397207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-144397OtherSTATE LICENSE