Provider Demographics
NPI:1922001072
Name:MONTEJO, RAUL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:EDWARD
Last Name:MONTEJO
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 1:2401 FRIST BLVD STE 2B
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4800
Mailing Address - Country:US
Mailing Address - Phone:772-460-7770
Mailing Address - Fax:407-369-4295
Practice Address - Street 1:2401 FRIST BLVD STE 2B
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4800
Practice Address - Country:US
Practice Address - Phone:772-460-7770
Practice Address - Fax:407-369-4295
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME557552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273461300Medicaid
FL372681900Medicaid
FL273461300Medicaid
FL372681900Medicaid
FL40258Medicare PIN