Provider Demographics
NPI:1558326389
Name:RICO, RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:RICO
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 1:1611 NW 12TH AVE
Mailing Address - Street 2:BOX 016960 M851
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-243-6358
Mailing Address - Fax:305-243-8470
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:BOX 016960 M851
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-243-6358
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76753207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2556278Medicaid
FL46201Medicare UPIN
FLG87607Medicare UPIN