Provider Demographics
NPI:1629058540
Name:RAISIS, LEONIDAS W (MD)
Entity Type:Individual
Prefix:
First Name:LEONIDAS
Middle Name:W
Last Name:RAISIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LEO
Other - Middle Name:W
Other - Last Name:RAISIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:211 EXECUTIVE DR STE 11
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3358
Mailing Address - Country:US
Mailing Address - Phone:302-731-2888
Mailing Address - Fax:302-731-7049
Practice Address - Street 1:4745 OGLETOWN STANTON RD STE 225
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-1387
Practice Address - Country:US
Practice Address - Phone:302-731-2888
Practice Address - Fax:302-731-7049
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECI0002996207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000097401Medicaid
DE000097401Medicaid
DE152595F17Medicare ID - Type Unspecified