Provider Demographics
NPI:1518015015
Name:RAEL, BRUCE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:RAEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 CIELO CT
Mailing Address - Street 2:STE A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-473-7673
Mailing Address - Fax:505-438-4501
Practice Address - Street 1:3022 CIELO CT
Practice Address - Street 2:STE A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-473-7673
Practice Address - Fax:505-438-4501
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOPT2370152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH4763Medicaid
NM1093780001Medicare NSC