Provider Demographics
NPI:1316079015
Name:COLON, J. RAFAEL (OTRL)
Entity type:Individual
Prefix:MR
First Name:J.
Middle Name:RAFAEL
Last Name:COLON
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7554 SW 84TH DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-8489
Mailing Address - Country:US
Mailing Address - Phone:352-871-1440
Mailing Address - Fax:352-376-0126
Practice Address - Street 1:120 NW 28TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2511
Practice Address - Country:US
Practice Address - Phone:352-246-5384
Practice Address - Fax:352-376-0126
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11408225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid