Provider Demographics
NPI:1912913740
Name:RAIZES, ELLIOT G (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:G
Last Name:RAIZES
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 1:1960 RIVERSIDE PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5945
Mailing Address - Country:US
Mailing Address - Phone:770-995-0466
Mailing Address - Fax:770-995-0472
Practice Address - Street 1:1960 RIVERSIDE PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5945
Practice Address - Country:US
Practice Address - Phone:770-995-0466
Practice Address - Fax:770-995-0472
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024478207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309509Medicaid
GA85000553GOtherGEORGIA BETTER HEALTHCARE
GA00344847AMedicaid
581958199OtherCHAMPUS
28131OtherBLUE CROSS BLUE SHIELD
9202955OtherUNITED HEALTH CARE
GA00344847AMedicaid
92BDBBPMedicare ID - Type Unspecified
GA309509Medicaid