Provider Demographics
NPI:1639813694
Name:GILDENGORN, RAPHAEL DAVID (MD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:DAVID
Last Name:GILDENGORN
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 1:14704 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2932
Mailing Address - Country:US
Mailing Address - Phone:347-419-2156
Mailing Address - Fax:
Practice Address - Street 1:74 WALLABOUT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-7830
Practice Address - Country:US
Practice Address - Phone:718-260-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333345208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics