Provider Demographics
NPI:1588651525
Name:ESPEJO, RAFAEL ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:ANTONIO
Last Name:ESPEJO
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 1:700 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7314
Mailing Address - Country:US
Mailing Address - Phone:352-547-3262
Mailing Address - Fax:352-622-5771
Practice Address - Street 1:1500 SW 1ST AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6504
Practice Address - Country:US
Practice Address - Phone:352-867-8311
Practice Address - Fax:352-867-1053
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225090-1207L00000X
OH35082283207L00000X
PAMD420149207L00000X
FLME119317207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME119317OtherMEDICAL LICENSE
OH2360690Medicaid
PA1438749OtherHIGHMARK BLUE SHIELD INDV
OH2360690Medicaid
PAH72337Medicare UPIN
OH4249691Medicare Oscar/Certification