Provider Demographics
NPI:1184730244
Name:RAFAEL, DANIEL (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:RAFAEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 BERGEN AVE
Mailing Address - Street 2:APT 114A
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-2541
Mailing Address - Country:US
Mailing Address - Phone:201-332-6539
Mailing Address - Fax:
Practice Address - Street 1:574 BERGEN AVE
Practice Address - Street 2:APT 114A
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-2541
Practice Address - Country:US
Practice Address - Phone:201-332-6539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA 02428152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2036207Medicaid
OE 058522OtherARBO
NJ2036207Medicaid
NJRA521766Medicare ID - Type Unspecified