Provider Demographics
NPI:1053371773
Name:RAIA, CAROLYN L (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:L
Last Name:RAIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1666
Mailing Address - Country:US
Mailing Address - Phone:718-876-2000
Mailing Address - Fax:718-876-2006
Practice Address - Street 1:360 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1666
Practice Address - Country:US
Practice Address - Phone:718-876-2000
Practice Address - Fax:718-876-2006
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1832662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01551308Medicaid
NM16J931Medicare ID - Type Unspecified
NYF81958Medicare UPIN