Provider Demographics
NPI: | 1467454058 |
---|---|
Name: | JUAREZ, RAFAEL GREGORY (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RAFAEL |
Middle Name: | GREGORY |
Last Name: | JUAREZ |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | RAFAEL |
Other - Middle Name: | GREGORY |
Other - Last Name: | JUAREZ |
Other - Suffix: | |
Other - Last Name Type: | Professional Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 2440 W HORIZON RIDGE PKWY |
Mailing Address - Street 2: | SUITE 100 |
Mailing Address - City: | HENDERSON |
Mailing Address - State: | NV |
Mailing Address - Zip Code: | 89052-2648 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 702-564-1858 |
Mailing Address - Fax: | 702-564-8058 |
Practice Address - Street 1: | 2440 W HORIZON RIDGE PKWY |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | HENDERSON |
Practice Address - State: | NV |
Practice Address - Zip Code: | 89052-2648 |
Practice Address - Country: | US |
Practice Address - Phone: | 702-564-1858 |
Practice Address - Fax: | 702-564-8058 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-08-12 |
Last Update Date: | 2012-03-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NV | 7003 | 207V00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NV | 002019521 | Medicaid | |
NV | 37792 | Medicare ID - Type Unspecified | NORIDIAN |
NV | F83040 | Medicare UPIN |