Provider Demographics
NPI:1497919245
Name:RAPHAEL, JONELLE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JONELLE
Middle Name:A
Last Name:RAPHAEL
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 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:208 MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5208
Practice Address - Country:US
Practice Address - Phone:508-973-2224
Practice Address - Fax:508-973-0394
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA253492207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099022AMedicaid
RIJR97162Medicaid
RIJR97162Medicaid