Provider Demographics
NPI:1679636120
Name:CUBILLAS MANRIQUE, RAUL EDUARDO (MD)
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:EDUARDO
Last Name:CUBILLAS MANRIQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 S ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-3094
Mailing Address - Country:US
Mailing Address - Phone:303-604-5000
Mailing Address - Fax:720-890-0364
Practice Address - Street 1:382 S ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-3094
Practice Address - Country:US
Practice Address - Phone:303-604-5000
Practice Address - Fax:720-890-0364
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0062775207RG0100X
FLME133167207RG0100X
GA63645207RG0100X
MN65634207RG0100X
IN01063094A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108726AMedicaid
CO900175048Medicaid