Provider Demographics
NPI:1609865807
Name:MARTIN, RAFAEL ERNESTO (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ERNESTO
Last Name:MARTIN
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:ESTACIONAMIENTO LA GALERIA SUITE 611
Mailing Address - Street 2:1451 AVENIDA ASHFORD ESQUINA NAIR
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00967-1507
Mailing Address - Country:US
Mailing Address - Phone:787-724-3407
Mailing Address - Fax:787-724-8945
Practice Address - Street 1:ESTACIONAMIENTO LA GALERIA SUITE 611
Practice Address - Street 2:1451 AVENIDA ASHFORD ESQUINA NAIR
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00967-1507
Practice Address - Country:US
Practice Address - Phone:787-724-3407
Practice Address - Fax:787-724-8945
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2679207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR92342Medicaid
92342Medicare ID - Type Unspecified
PR92342Medicaid