Provider Demographics
NPI:1467465997
Name:RAISS, JOHN CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CARL
Last Name:RAISS
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:2021 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 750-E
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2208
Mailing Address - Country:US
Mailing Address - Phone:310-829-4787
Mailing Address - Fax:310-829-4057
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 750-E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2208
Practice Address - Country:US
Practice Address - Phone:310-829-4787
Practice Address - Fax:310-829-4057
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC389482084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A88061Medicare UPIN