Basic Information
Provider Information | |||||||||
NPI: | 1225291768 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LI JIMENEZ | ||||||||
FirstName: | RAFAEL | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LI | ||||||||
OtherFirstName: | RAFAEL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9602 | ||||||||
Address2: |   | ||||||||
City: | MISSION HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913469602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188375559 | ||||||||
FaxNumber: | 8187924793 | ||||||||
Practice Location | |||||||||
Address1: | 11333 N SEPULVEDA BLVD | ||||||||
Address2: |   | ||||||||
City: | MISSION HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913451116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188697253 | ||||||||
FaxNumber: | 8188981682 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2008 | ||||||||
LastUpdateDate: | 06/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208000000X | A114957 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | A114957 | 01 | CA | MEDICAL LICENSE | OTHER | FL2508971 | 01 | CA | DEA | OTHER |