Provider Demographics
NPI:1083742829
Name:FORNARIS, RAFAEL JORGE (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:JORGE
Last Name:FORNARIS
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 1:863 CELESTIAL VW
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-4374
Mailing Address - Country:US
Mailing Address - Phone:210-833-0389
Mailing Address - Fax:
Practice Address - Street 1:434 NW LOOP 1604
Practice Address - Street 2:SUITE 1204
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232
Practice Address - Country:US
Practice Address - Phone:210-946-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine