Provider Demographics
NPI:1124481544
Name:RAISANEN, TOM DAVID (MD)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:DAVID
Last Name:RAISANEN
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 1:50384 ROCKY SHORES RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-9213
Mailing Address - Country:US
Mailing Address - Phone:320-267-4247
Mailing Address - Fax:
Practice Address - Street 1:205 OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:LAURIUM
Practice Address - State:MI
Practice Address - Zip Code:49913-2134
Practice Address - Country:US
Practice Address - Phone:906-337-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-02
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301110056207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program