Provider Demographics
NPI:1326021361
Name:MALABANAN, RAQUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:
Last Name:MALABANAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2961 HUBBARD TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5803
Mailing Address - Country:US
Mailing Address - Phone:815-636-8591
Mailing Address - Fax:
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091422208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091422Medicaid
ILH14335Medicare UPIN
IL580700Medicare ID - Type UnspecifiedMEDICARE