Basic Information
| Provider Information | |||||||||
| NPI: | 1528145786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYE | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13517 LA MIRADA CIR | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334143955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613242976 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6618 W ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614985007 | ||||||||
| FaxNumber: | 5614963088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | OPC001513 | FL | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | OPC1513 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 014701500 | 05 | FL | MEDICAID |