Provider Demographics
NPI:1144281437
Name:DERAIMO, ANTHONY J (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:J
Last Name:DERAIMO
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:PO BOX 9210
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-9210
Mailing Address - Country:US
Mailing Address - Phone:850-476-8602
Mailing Address - Fax:850-474-3518
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00484532085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043212100Medicaid
FL17663OtherBCBS OF FLORIDA
FL300070293OtherRR MEDICARD
AL57477OtherBCBS OF ALABAMA
AL009003570OtherALABAMA EDS MEDICAID
FL17663OtherBCBS OF FLORIDA
FL17663ZMedicare ID - Type UnspecifiedMEDICARE