Provider Demographics
NPI:1073508891
Name:SHAPIRO, RAPHAEL I (MD)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:I
Last Name:SHAPIRO
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 1:1631 HOSPITAL DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4728
Mailing Address - Country:US
Mailing Address - Phone:505-913-3975
Mailing Address - Fax:505-986-8001
Practice Address - Street 1:1631 HOSPITAL DR
Practice Address - Street 2:SUITE 240
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4728
Practice Address - Country:US
Practice Address - Phone:505-913-3975
Practice Address - Fax:505-986-8001
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2010-08-12
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
NM80253174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
202007840OtherPRESBYTERIAN HEALTH PLANS
740201OtherUHC
10088011OtherLOVELACE
NMNM012490OtherBCBS NM
PROVP16424OtherMOLINA
NM12781Medicaid
38702OtherCCN
NM346633805Medicare PIN
10088011OtherLOVELACE
NM2127877Medicare ID - Type Unspecified