Provider Demographics
NPI:1508426289
Name:RAYMUNDO, MARC JOSEPH CRISTOBAL
Entity Type:Individual
Prefix:
First Name:MARC JOSEPH
Middle Name:CRISTOBAL
Last Name:RAYMUNDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:786 D STREET
Mailing Address - Street 2:
Mailing Address - City:FORT RICHARDSON
Mailing Address - State:AK
Mailing Address - Zip Code:99505
Mailing Address - Country:US
Mailing Address - Phone:907-384-3810
Mailing Address - Fax:
Practice Address - Street 1:786 D ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99505
Practice Address - Country:US
Practice Address - Phone:907-384-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-16
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE32987208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program