Provider Demographics
NPI:1972894921
Name:BALBINO, RAPHAEL TITO (MD)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:TITO
Last Name:BALBINO
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:PO BOX 3162
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3162
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:841 PRUDENTIAL DR STE 180
Practice Address - Street 2:ATTN: CREDENTIALING SPECIALIST
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8350
Practice Address - Country:US
Practice Address - Phone:904-202-4600
Practice Address - Fax:904-202-4614
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01760207Q00000X
FLME123543207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014936900Medicaid
FL014936900Medicaid