Provider Demographics
NPI:1023047297
Name:RUSYNYK, RAPHAEL ALEXANDER (DO)
Entity type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:ALEXANDER
Last Name:RUSYNYK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:417A RACETRACK RD NW STE 2
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-4604
Mailing Address - Country:US
Mailing Address - Phone:850-863-5990
Mailing Address - Fax:850-862-0041
Practice Address - Street 1:141 MACK BAYOU LOOP STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7194
Practice Address - Country:US
Practice Address - Phone:850-863-5990
Practice Address - Fax:850-862-0041
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8902207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266728200Medicaid
FLH84831Medicare UPIN
FLK4433Medicare ID - Type Unspecified