Provider Demographics
NPI:1881640290
Name:RAFFERTY, BRIAN S (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:RAFFERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:200 WALNUT ST
Practice Address - Street 2:
Practice Address - City:TRAER
Practice Address - State:IA
Practice Address - Zip Code:50675-1142
Practice Address - Country:US
Practice Address - Phone:319-478-8198
Practice Address - Fax:319-478-2933
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA29544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0102434Medicaid
IAE93528Medicare UPIN
IA0102434Medicaid