Basic Information
| Provider Information | |||||||||
| NPI: | 1174670863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRICENO | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | SEGUNDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 816759 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330810759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549642450 | ||||||||
| FaxNumber: | 9549646084 | ||||||||
| Practice Location | |||||||||
| Address1: | 3363 SHERIDAN ST | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330213664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549642450 | ||||||||
| FaxNumber: | 9549646084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2013 | ||||||||
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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 | MD29002 | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME97155 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A97677 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003117000 | 05 | FL | MEDICAID | 14P2T | 01 | FL | FLORIDA BLUE | OTHER |