Provider Demographics
NPI:1861447708
Name:PELEGRIN, RAFAEL A (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:A
Last Name:PELEGRIN
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 1:10661 N KENDALL DR
Mailing Address - Street 2:SUITE 113
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1550
Mailing Address - Country:US
Mailing Address - Phone:305-279-1929
Mailing Address - Fax:305-279-1935
Practice Address - Street 1:10661 N KENDALL DR
Practice Address - Street 2:SUITE 113
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1550
Practice Address - Country:US
Practice Address - Phone:305-279-1929
Practice Address - Fax:305-279-1935
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC47510Medicare UPIN
FLE6802Medicare ID - Type Unspecified