Provider Demographics
NPI:1073545257
Name:PASTRANA LABORDE, RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:PASTRANA LABORDE
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 1:735 AVE PONCE DE LEON STE 816
Mailing Address - Street 2:TORRE MEDICA AUXILIO MUTUO
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917
Mailing Address - Country:US
Mailing Address - Phone:787-763-1025
Mailing Address - Fax:787-250-1928
Practice Address - Street 1:735 AVE PONCE DE LEON
Practice Address - Street 2:STE 816
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00917-5022
Practice Address - Country:US
Practice Address - Phone:787-505-5482
Practice Address - Fax:787-250-1928
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96195207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275571800Medicaid
FL53390OtherBLUE CROSS BLUE SHIELD
FL53390OtherBLUE CROSS BLUE SHIELD
PRI55999Medicare UPIN
FLI55999Medicare UPIN
PRU7730ZMedicare PIN
FLU7730ZMedicare PIN