Provider Demographics
NPI:1225379449
Name:MEDIAVILLA, RAFAEL (MS-ESL)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:
Last Name:MEDIAVILLA
Suffix:
Gender:M
Credentials:MS-ESL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 RENWICK DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2037
Mailing Address - Country:US
Mailing Address - Phone:203-612-4870
Mailing Address - Fax:
Practice Address - Street 1:33 RENWICK DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2037
Practice Address - Country:US
Practice Address - Phone:203-612-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1664735174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist