Provider Demographics
NPI:1427046341
Name:RICAURTE, JUAN CARLOS (MD)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:RICAURTE
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 1:1300 NORTH VERMONT AVE, SUITE 806
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6302
Mailing Address - Country:US
Mailing Address - Phone:323-663-6790
Mailing Address - Fax:323-663-6791
Practice Address - Street 1:1300 NORTH VERMONT AVE, SUITE 806
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6302
Practice Address - Country:US
Practice Address - Phone:323-663-6790
Practice Address - Fax:323-663-6791
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA701690207RI0200X
CA070169207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H11943Medicare UPIN