Provider Demographics
NPI:1578893335
Name:RAPHAEL KHORRAN MD PA
Entity Type:Organization
Organization Name:RAPHAEL KHORRAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHORRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-875-7916
Mailing Address - Street 1:512 S DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3906
Mailing Address - Country:US
Mailing Address - Phone:813-875-7916
Mailing Address - Fax:816-875-5513
Practice Address - Street 1:512 S DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3906
Practice Address - Country:US
Practice Address - Phone:813-875-7916
Practice Address - Fax:816-875-5513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0042171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30601Medicare PIN