Provider Demographics
NPI:1366440125
Name:ZELAYA, RAUL B (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:B
Last Name:ZELAYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 SW MAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6684
Mailing Address - Country:US
Mailing Address - Phone:386-752-6506
Mailing Address - Fax:386-752-6508
Practice Address - Street 1:1188 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6684
Practice Address - Country:US
Practice Address - Phone:386-752-6506
Practice Address - Fax:386-752-6508
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 34230207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
96003OtherBCBS
D78953Medicare UPIN
FLK5879Medicare ID - Type Unspecified