Provider Demographics
NPI:1982600417
Name:TALLO, RAUL (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:TALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT.
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 PABLO ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3818
Practice Address - Country:US
Practice Address - Phone:863-284-5941
Practice Address - Fax:863-284-5199
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63965207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372794700Medicaid
FL23184ZMedicare PIN
FLF64696Medicare UPIN