Healthcare Provider Details

I. General information

NPI: 1003115155
Provider Name (Legal Business Name): JUSTIN MATTHEW RAFAEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 N KENDALL DR
MIAMI FL
33176-2118
US

IV. Provider business mailing address

8900 N KENDALL DR
MIAMI FL
33176-2118
US

V. Phone/Fax

Practice location:
  • Phone: 786-596-1960
  • Fax: 305-273-0254
Mailing address:
  • Phone: 215-888-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number256879
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME114125
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: