Healthcare Provider Details

I. General information

NPI: 1942144001
Provider Name (Legal Business Name): RAFAEL PORFIRIO DE AGUIAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE. 2ND FLOOR BORDLEY
ST. LOUIS MO
63110
US

IV. Provider business mailing address

3635 VISTA AVE. 2ND FLOOR BORDLEY
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-2777
  • Fax: 314-617-2779
Mailing address:
  • Phone: 314-617-2777
  • Fax: 314-617-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: