Provider Demographics
NPI:1003974882
Name:RAPHAEL, RAFIK M (MD)
Entity Type:Individual
Prefix:
First Name:RAFIK
Middle Name:M
Last Name:RAPHAEL
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 1:9280 HIGHWAY 5
Mailing Address - Street 2:SUITE G
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1501
Mailing Address - Country:US
Mailing Address - Phone:770-944-3525
Mailing Address - Fax:770-944-8544
Practice Address - Street 1:9280 HIGHWAY 5
Practice Address - Street 2:SUITE G
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1501
Practice Address - Country:US
Practice Address - Phone:770-944-3525
Practice Address - Fax:770-944-8544
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00110635DMedicaid
GA00110635DMedicaid
GA08BBTJJMedicare PIN