Provider Demographics
NPI:1467558130
Name:RAPHAEL, IRVING G (MD)
Entity Type:Individual
Prefix:
First Name:IRVING
Middle Name:G
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 1:475 IRVING AVE
Mailing Address - Street 2:SUITE 418
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1756
Mailing Address - Country:US
Mailing Address - Phone:315-426-0190
Mailing Address - Fax:315-426-0192
Practice Address - Street 1:475 IRVING AVE
Practice Address - Street 2:SUITE 418
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1756
Practice Address - Country:US
Practice Address - Phone:315-426-0190
Practice Address - Fax:315-426-0192
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY113215207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
51656FMedicare ID - Type Unspecified
A44768Medicare UPIN