Provider Demographics
NPI:1699779173
Name:IRRA, PAUL R
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:IRRA
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 1:5400 PARK CENTRAL CT
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-6001
Mailing Address - Country:US
Mailing Address - Phone:239-593-7000
Mailing Address - Fax:239-593-7008
Practice Address - Street 1:5400 PARK CENTRAL CT
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-5923
Practice Address - Country:US
Practice Address - Phone:239-593-7000
Practice Address - Fax:239-593-7008
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065935208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376380300Medicaid
FL26236OtherBLUECROSSBLUESHIELD
FLF91218Medicare UPIN