Provider Demographics
NPI:1477550150
Name:LASTRA, RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:LASTRA
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 1:138 AVE WINSTON CHURCHILL
Mailing Address - Street 2:PMB 149
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:TORRE AUXILIO MUTUO PONCE DE LEON AVE 735
Practice Address - Street 2:SUITE 516
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917
Practice Address - Country:US
Practice Address - Phone:787-764-6403
Practice Address - Fax:787-756-8926
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9566207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG41545Medicare UPIN
PR83348Medicare ID - Type UnspecifiedMEDICARE