Healthcare Provider Details

I. General information

NPI: 1629325337
Provider Name (Legal Business Name): RAUL ALFREDO FAGUNDEZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 E 20TH ST
HIALEAH FL
33013-4135
US

IV. Provider business mailing address

483 E 20TH ST
HIALEAH FL
33013-4135
US

V. Phone/Fax

Practice location:
  • Phone: 786-704-5176
  • Fax:
Mailing address:
  • Phone: 786-704-5176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9328451
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: