Provider Demographics
NPI:1629007562
Name:RAFDAL, TRAVIS DEAN (DC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DEAN
Last Name:RAFDAL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11790 JEFFERSON AVE
Mailing Address - Street 2:#205
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606
Mailing Address - Country:US
Mailing Address - Phone:757-873-8701
Mailing Address - Fax:757-873-6737
Practice Address - Street 1:11790 JEFFERSON AVE
Practice Address - Street 2:#205
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-873-8701
Practice Address - Fax:757-873-6737
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556169111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA187447OtherANTHEM BCBS
00W777R02Medicare ID - Type Unspecified
V07671Medicare UPIN