Provider Demographics
NPI:1932189008
Name:KNISLEY, RAYMOND R (DO)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:R
Last Name:KNISLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7652 ASHLEY PARK CT STE 305
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6199
Mailing Address - Country:US
Mailing Address - Phone:407-299-7333
Mailing Address - Fax:863-589-5639
Practice Address - Street 1:1255 STATE ROAD 60 E STE 100
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4310
Practice Address - Country:US
Practice Address - Phone:863-589-5685
Practice Address - Fax:863-589-5639
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12508207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HU572ZMedicare PIN