Provider Demographics
NPI:1205161015
Name:MARCOS RAYMUNDO, LUIS AUGUSTO (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:AUGUSTO
Last Name:MARCOS RAYMUNDO
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:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:631-638-4170
Practice Address - Street 1:HSC T15 080
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8153
Practice Address - Country:US
Practice Address - Phone:631-444-3490
Practice Address - Fax:631-638-7518
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2015-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21387207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06575513OtherMAGNOLIA
MS9576702OtherAETNA
MS06575513Medicaid
MS302I449980OtherMEDICARE PTAN
3310476OtherUHC