Provider Demographics
NPI:1609967637
Name:DIRAIMONDO, CARL ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ALAN
Last Name:DIRAIMONDO
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 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:1111 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5548
Practice Address - Country:US
Practice Address - Phone:920-682-6376
Practice Address - Fax:920-652-0115
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43361207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34106600Medicaid
WI076500372Medicare PIN
WIH30397Medicare UPIN
WI34106600Medicaid