Provider Demographics
NPI:1619003167
Name:RAPHAEL, GORDON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:DAVID
Last Name:RAPHAEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4915 AUBURN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2636
Mailing Address - Country:US
Mailing Address - Phone:301-907-3442
Mailing Address - Fax:301-907-6835
Practice Address - Street 1:4915 AUBURN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2636
Practice Address - Country:US
Practice Address - Phone:301-907-3442
Practice Address - Fax:301-907-6835
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD28918207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE78943Medicare UPIN