Provider Demographics
NPI:1497784748
Name:OTERO, RAFAEL F (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:F
Last Name:OTERO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1662
Mailing Address - Country:US
Mailing Address - Phone:903-838-3711
Mailing Address - Fax:903-838-8879
Practice Address - Street 1:5425 PLAZA DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1662
Practice Address - Country:US
Practice Address - Phone:903-838-3711
Practice Address - Fax:903-838-8879
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR85-3P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR80433OtherAR BC/BS
TXR58294Medicare UPIN
AR80433OtherAR BC/BS
TX00JD51Medicare PIN