Basic Information
| Provider Information | |||||||||
| NPI: | 1730296211 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAFAEL R.V. LUCILA MD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LUCILA MEDICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 ALLWOOD RD | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070121923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732496202 | ||||||||
| FaxNumber: | 9732496203 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 ALLWOOD RD | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070121923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732496202 | ||||||||
| FaxNumber: | 9732496203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | LUCILA | ||||||||
| AuthorizedOfficialFirstName: | RAFAEL | ||||||||
| AuthorizedOfficialMiddleName: | R.V. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9732496202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MA061330 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6672001 | 05 | NJ | MEDICAID |