Provider Demographics
NPI:1548377021
Name:RAISTRICK, JONATHAN SCOTT (ND)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:SCOTT
Last Name:RAISTRICK
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2614
Mailing Address - Country:US
Mailing Address - Phone:860-945-1004
Mailing Address - Fax:860-945-9988
Practice Address - Street 1:640 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2614
Practice Address - Country:US
Practice Address - Phone:860-945-1004
Practice Address - Fax:860-945-9988
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000124175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath