Provider Demographics
NPI:1831291285
Name:DEPESTRE, RAYNOLD (MD)
Entity Type:Individual
Prefix:
First Name:RAYNOLD
Middle Name:
Last Name:DEPESTRE
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 1:3704 LANAMER RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133
Mailing Address - Country:US
Mailing Address - Phone:410-655-4946
Mailing Address - Fax:
Practice Address - Street 1:3704 LANAMER RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-1517
Practice Address - Country:US
Practice Address - Phone:410-265-5400
Practice Address - Fax:410-298-3917
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD27157207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD484691500Medicaid
B69200Medicare UPIN
MDR2725Medicare ID - Type Unspecified