Provider Demographics
NPI:1295059038
Name:RAFAELIAN, OLGA ALEXANDROVNA (MD)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:ALEXANDROVNA
Last Name:RAFAELIAN
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 1:5940 WESTPORT LN
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-5418
Mailing Address - Country:US
Mailing Address - Phone:239-631-9858
Mailing Address - Fax:
Practice Address - Street 1:1803 W MARCH LN STE D
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6414
Practice Address - Country:US
Practice Address - Phone:916-364-8395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1286382084P0800X
MDD733062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104062300Medicaid