Provider Demographics
NPI:1780672923
Name:RAVELO, RAUL (MD)
Entity type:Individual
Prefix:DR
First Name:RAUL
Middle Name:
Last Name:RAVELO
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:78 SW 13TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2479
Practice Address - Country:US
Practice Address - Phone:305-643-0404
Practice Address - Fax:305-643-0403
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00456832085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01598280OtherRR MEDICARE
FLP995035OtherFREEDOM
FL11643OtherBCBS
FL209644OtherAVMED
FL6363558OtherCIGNA
FLP936576OtherOPTIMUM
FL1073732OtherWELLCARE
FL4153OtherDIMENSION
FL4153OtherDIMENSION
FL209644OtherAVMED
FLE71805Medicare UPIN