Provider Demographics
NPI:1649298027
Name:RAUCHWARGER, ALAN IVAN (OD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:IVAN
Last Name:RAUCHWARGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 ATLANTIC BLVD
Mailing Address - Street 2:SUITE 62
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-8255
Mailing Address - Country:US
Mailing Address - Phone:904-721-7700
Mailing Address - Fax:904-721-0051
Practice Address - Street 1:9400 ATLANTIC BLVD
Practice Address - Street 2:62
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-8255
Practice Address - Country:US
Practice Address - Phone:904-721-7700
Practice Address - Fax:904-721-0051
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011047500Medicaid
FL19421SMedicare PIN
FL011047500Medicaid
FL19121XMedicare PIN