Provider Demographics
NPI:1194958603
Name:CRESPO FERNANDEZ, RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CRESPO FERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 NW 42ND AVE
Mailing Address - Street 2:FL 5
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126
Mailing Address - Country:US
Mailing Address - Phone:305-504-7885
Mailing Address - Fax:
Practice Address - Street 1:16201 SW 95TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-3459
Practice Address - Country:US
Practice Address - Phone:305-400-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN 613208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015206000Medicaid