Provider Demographics
NPI:1154341907
Name:RAFATJOO, ALI REZA (MD)
Entity type:Individual
Prefix:MR
First Name:ALI
Middle Name:REZA
Last Name:RAFATJOO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:360 SAN MIGUEL DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7853
Mailing Address - Country:US
Mailing Address - Phone:949-640-4455
Mailing Address - Fax:949-640-4456
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:SUITE 206
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-640-4455
Practice Address - Fax:949-640-4456
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54980207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA054980OtherMEDICAL LICENSE
CAG79344Medicare UPIN