Healthcare Provider Details

I. General information

NPI: 1417978644
Provider Name (Legal Business Name): RAFAEL RUBALCAVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15034 IMPERIAL HWY
LA MIRADA CA
90638-1301
US

IV. Provider business mailing address

15034 IMPERIAL HWY
LA MIRADA CA
90638-1301
US

V. Phone/Fax

Practice location:
  • Phone: 562-902-3000
  • Fax: 562-902-9563
Mailing address:
  • Phone: 562-902-3000
  • Fax: 562-902-9563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG79047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: