Provider Demographics
NPI:1073692000
Name:KHORRAN, RAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:KHORRAN
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 1:2106 S LOIS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5659
Mailing Address - Country:US
Mailing Address - Phone:813-844-4200
Mailing Address - Fax:813-844-1919
Practice Address - Street 1:2106 S LOIS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5659
Practice Address - Country:US
Practice Address - Phone:813-844-4200
Practice Address - Fax:813-844-1919
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006300600Medicaid
FL006300600Medicaid
FL30601ZMedicare PIN