Provider Demographics
NPI:1821007055
Name:CARCAMO, RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CARCAMO
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 1:647 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-5802
Mailing Address - Country:US
Mailing Address - Phone:626-858-5199
Mailing Address - Fax:626-858-5299
Practice Address - Street 1:647 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-5802
Practice Address - Country:US
Practice Address - Phone:626-858-5199
Practice Address - Fax:626-858-5299
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A666750Medicaid
CAH48587Medicare UPIN
CA00A666750Medicaid