=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255745584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT AFRA MD A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2014
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8300 UNIVERSITY AVE
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-9323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-243-4882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1251 VIA MIL CUMBRES
-----------------------------------------------------
City | SOLANA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92075-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-243-4882
-----------------------------------------------------
Fax | 858-794-7675
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT AFRA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 619-243-4882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | A96247
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------