Provider Demographics
NPI:1477537413
Name:RAFANOV, VLADIMIR (MD)
Entity type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:RAFANOV
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 1:804 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-2202
Mailing Address - Country:US
Mailing Address - Phone:916-371-1616
Mailing Address - Fax:916-979-1110
Practice Address - Street 1:804 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-2202
Practice Address - Country:US
Practice Address - Phone:916-371-1616
Practice Address - Fax:916-979-1110
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA563442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A563440Medicaid
CA00A563441Medicaid
G75984Medicare UPIN
CA00A563441Medicaid