Healthcare Provider Details

I. General information

NPI: 1871925297
Provider Name (Legal Business Name): RAFAEL ALBERTO JUSTINIANO MAGRANER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1501 KINGS HWY
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0000
  • Fax:
Mailing address:
  • Phone: 787-354-1896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number312265
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20938
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: