Provider Demographics
NPI:1376643858
Name:RETINO, RAFAEL T (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:T
Last Name:RETINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE RAFAEL
Other - Middle Name:T
Other - Last Name:RETINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11600 INDIAN HILLS RD
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1225
Mailing Address - Country:US
Mailing Address - Phone:818-838-4590
Mailing Address - Fax:818-838-7509
Practice Address - Street 1:11600 INDIAN HILLS RD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1225
Practice Address - Country:US
Practice Address - Phone:818-838-4590
Practice Address - Fax:818-838-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA046422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F03137Medicare UPIN