Provider Demographics
NPI:1033151287
Name:CHAN, RAFAEL COMACHO (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:COMACHO
Last Name:CHAN
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-467-9605
Practice Address - Street 1:1450 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-923-4423
Practice Address - Fax:817-923-3176
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE21692085R0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132672010Medicaid
TX8S3354OtherBLUE CROSS OF TEXAS
TX132672009Medicaid
TX132672010Medicaid
TX8G5173Medicare PIN
TXP00227903Medicare PIN
TX8D6196Medicare PIN