Healthcare Provider Details

I. General information

NPI: 1003317306
Provider Name (Legal Business Name): DR. RAFAEL ELIAS OLIVARES CHAYEB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 ALTA RD
SAN DIEGO CA
92179-0001
US

IV. Provider business mailing address

1260 MORENA BLVD STE 100
SAN DIEGO CA
92110-3850
US

V. Phone/Fax

Practice location:
  • Phone: 619-691-6947
  • Fax:
Mailing address:
  • Phone: 619-398-0355
  • Fax: 619-398-0350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY35650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: