Basic Information
| Provider Information | |||||||||
| NPI: | 1972894921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALBINO | ||||||||
| FirstName: | RAPHAEL | ||||||||
| MiddleName: | TITO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3162 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 841 PRUDENTIAL DR STE 180 | ||||||||
| Address2: | ATTN: CREDENTIALING SPECIALIST | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042024600 | ||||||||
| FaxNumber: | 9042024614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2011 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2013-01760 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME123543 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | ME123543 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014936900 | 05 | FL | MEDICAID |