Provider Demographics
NPI:1073554838
Name:ENUKASHVILI, RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:ENUKASHVILI
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 1:21 KILMER DRIVE
Mailing Address - Street 2:BLDG 2 SUITE C
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-1568
Mailing Address - Country:US
Mailing Address - Phone:732-617-2988
Mailing Address - Fax:732-617-2987
Practice Address - Street 1:21 KILMER DRIVE
Practice Address - Street 2:BLDG 2 SUITE C
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-1568
Practice Address - Country:US
Practice Address - Phone:732-617-2988
Practice Address - Fax:732-617-2987
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA064386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8651108Medicaid
NJ2017306OtherAETNA
NJP1123503OtherOXFORD
NJ2017306OtherAETNA
NJP1123503OtherOXFORD