Provider Demographics
NPI:1780614578
Name:ROURE, A RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:A
Middle Name:RAFAEL
Last Name:ROURE
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 1:35202 3RD AVE #370
Mailing Address - Street 2:
Mailing Address - City:FT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:904-651-2888
Mailing Address - Fax:
Practice Address - Street 1:DWIGHT D EISENHOWER ARMY MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:FT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-6158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 72475207X00000X
FLME72475174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272246100Medicaid
FL03407ZMedicare ID - Type UnspecifiedINDIVIDUAL
FLK7654Medicare ID - Type UnspecifiedGROUP
FL272246100Medicaid