Healthcare Provider Details

I. General information

NPI: 1699296319
Provider Name (Legal Business Name): RAFAEL FRANCISCO CHUPECO GO MD, MBA, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2082 MESQUITE AVE STE A
LAKE HAVASU CITY AZ
86403-6710
US

IV. Provider business mailing address

PO BOX 3539
LAKE HAVASU CITY AZ
86405-3539
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-2727
  • Fax: 928-453-2828
Mailing address:
  • Phone: 928-453-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125070077
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number4301509437
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: