Provider Demographics
NPI:1861576290
Name:REISFELD, RAFAEL
Entity type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:
Last Name:REISFELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 S BEVERLY DRIVE
Mailing Address - Street 2:#500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035
Mailing Address - Country:US
Mailing Address - Phone:310-557-3037
Mailing Address - Fax:310-557-3554
Practice Address - Street 1:1125 S BEVERLY DRIVE
Practice Address - Street 2:#500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035
Practice Address - Country:US
Practice Address - Phone:310-557-3037
Practice Address - Fax:310-557-3554
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0636480208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A32774Medicaid
A26928Medicare UPIN
CA00A32774Medicaid