Provider Demographics
NPI:1124001623
Name:RAFFERTY, MOIRA (MD)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:RAFFERTY
Suffix:
Gender:F
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:PO BOX 11889
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24506-1889
Mailing Address - Country:US
Mailing Address - Phone:434-947-3944
Mailing Address - Fax:434-544-2316
Practice Address - Street 1:2215 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2115
Practice Address - Country:US
Practice Address - Phone:434-947-3944
Practice Address - Fax:866-617-8273
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230989207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA110222942OtherMEDICARE RAILROAD CARRIER
VA5858712Medicaid
VA110008111Medicare PIN
VA110222942OtherMEDICARE RAILROAD CARRIER