Basic Information
Provider Information | |||||||||
NPI: | 1376602649 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAYTAN | ||||||||
FirstName: | RAFAEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 MERCY WAY | ||||||||
Address2: | SUITE 320-330 | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648044524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4177815387 | ||||||||
FaxNumber: | 4177817174 | ||||||||
Practice Location | |||||||||
Address1: | 100 MERCY WAY | ||||||||
Address2: | SUITE 320-330 | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648044524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4177815387 | ||||||||
FaxNumber: | 4177817174 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2006 | ||||||||
LastUpdateDate: | 03/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 2006038051 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | 2006038051 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 200418840C | 05 | KS |   | MEDICAID | 200101900A | 05 | OK |   | MEDICAID | 206295701 | 05 | MO |   | MEDICAID | P00800214 | 01 | MO | RAIL ROAD MEDICARE | OTHER |