Provider Demographics
NPI:1356564264
Name:TIRADO SIRAGUSA, RAFAEL ANTONIO
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:ANTONIO
Last Name:TIRADO SIRAGUSA
Suffix:
Gender:M
Credentials:
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 328
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674
Mailing Address - Country:US
Mailing Address - Phone:787-854-7363
Mailing Address - Fax:787-854-7368
Practice Address - Street 1:#93 CALLE MCKINLEY
Practice Address - Street 2:PASEO ATENAS
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-854-7363
Practice Address - Fax:787-854-7368
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0965190207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
29504Medicare ID - Type Unspecified