Provider Demographics
NPI:1104900034
Name:CARRELLE, RAYMOND
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:CARRELLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24810 BURNT PINE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-1973
Mailing Address - Country:US
Mailing Address - Phone:239-992-4444
Mailing Address - Fax:239-992-4400
Practice Address - Street 1:24810 BURNT PINE DR STE 3
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134
Practice Address - Country:US
Practice Address - Phone:239-992-4444
Practice Address - Fax:239-992-4400
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218930207Q00000X
FL0083026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02164327Medicaid
NY02164327Medicaid
NYCC9599Medicare PIN