Provider Demographics
NPI:1265477053
Name:LAO, RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:LAO
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 232
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-0232
Mailing Address - Country:US
Mailing Address - Phone:812-882-6416
Mailing Address - Fax:812-882-8620
Practice Address - Street 1:700 WILLOW ST
Practice Address - Street 2:SUITE 100
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1028
Practice Address - Country:US
Practice Address - Phone:812-882-6416
Practice Address - Fax:812-882-8620
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042614A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100384200BMedicaid
IN100384200BMedicaid
IN444650Medicare PIN
IL234590Medicare PIN