Provider Demographics
NPI:1780870063
Name:DE RAET, OLIVIER JEAN (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:OLIVIER
Middle Name:JEAN
Last Name:DE RAET
Suffix:
Gender:
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-0000
Mailing Address - Fax:
Practice Address - Street 1:5255 LOUGHBORO RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-2633
Practice Address - Country:US
Practice Address - Phone:202-537-4560
Practice Address - Fax:202-537-4006
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49076208M00000X, 207R00000X
390200000X
DCMD210002863208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71274766Medicaid
COCOA104951Medicare PIN