Provider Demographics
NPI:1336137991
Name:SKIDMORE, RAQUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:
Last Name:SKIDMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RAQUEL
Other - Middle Name:
Other - Last Name:SKIDMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:219 FOREST PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405
Mailing Address - Country:US
Mailing Address - Phone:850-215-9418
Mailing Address - Fax:850-215-9419
Practice Address - Street 1:219 FOREST PARK CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4920
Practice Address - Country:US
Practice Address - Phone:850-215-9418
Practice Address - Fax:850-215-9419
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14439207K00000X
FLACN244207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006732100Medicaid
FLACN244OtherFL PHYSICIAN LICENSE
12542810OtherCAQH ID
PR14439OtherLICENCIA