Basic Information
| Provider Information | |||||||||
| NPI: | 1154303394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSOTEO | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 361 E WATERLOO RD | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307737866 | ||||||||
| FaxNumber: | 3307735090 | ||||||||
| Practice Location | |||||||||
| Address1: | 361 E WATERLOO RD | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307737866 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0224635 | 05 | OH | MEDICAID |