Provider Demographics
NPI:1649712373
Name:DAVIDOV, RAFIE (APN-CNP)
Entity type:Individual
Prefix:
First Name:RAFIE
Middle Name:
Last Name:DAVIDOV
Suffix:
Gender:F
Credentials:APN-CNP
Other - Prefix:
Other - First Name:RAFIE
Other - Middle Name:
Other - Last Name:DZHUDZHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 S FRONTAGE RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4903
Mailing Address - Country:US
Mailing Address - Phone:630-972-8228
Mailing Address - Fax:630-972-8229
Practice Address - Street 1:800 BIESTERFIELD RD STE G01
Practice Address - Street 2:WIMMER BUILDING
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3372
Practice Address - Country:US
Practice Address - Phone:847-981-3680
Practice Address - Fax:847-956-5122
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014789363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1720371669OtherGROUP PRACTICE NPI