Provider Demographics
NPI:1730296047
Name:MIMBELA, RAFAEL ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ALBERTO
Last Name:MIMBELA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78523-5718
Mailing Address - Country:US
Mailing Address - Phone:956-350-0779
Mailing Address - Fax:956-350-3006
Practice Address - Street 1:4770 N EXPRESSWAY # 83
Practice Address - Street 2:SUITE 102
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-4165
Practice Address - Country:US
Practice Address - Phone:956-350-0779
Practice Address - Fax:956-350-3006
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK18782080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110734402Medicaid
TX614370OtherMEDICARE