Provider Demographics
NPI:1205121324
Name:RAPHAEL, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
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 1:5823 WIDEWATERS PKWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3084
Mailing Address - Country:US
Mailing Address - Phone:315-500-7546
Mailing Address - Fax:
Practice Address - Street 1:5823 WIDEWATERS PKWY
Practice Address - Street 2:SUITE 4
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3084
Practice Address - Country:US
Practice Address - Phone:315-500-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT199988207R00000X
MA262904207ND0101X
NY282257-1207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine