Provider Demographics
NPI:1093773103
Name:RAFFERTY, THOMAS D (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:RAFFERTY
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 1:736 HUNT CLUB WAY
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-4019
Mailing Address - Country:US
Mailing Address - Phone:440-617-5884
Mailing Address - Fax:
Practice Address - Street 1:736 HUNT CLUB WAY
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-4019
Practice Address - Country:US
Practice Address - Phone:440-617-5884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046972R2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A80415Medicare UPIN
RA0516311Medicare ID - Type Unspecified