Provider Demographics
NPI:1720068679
Name:SQUITIERI, RAFAEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:P
Last Name:SQUITIERI
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 1:1177 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5572
Mailing Address - Country:US
Mailing Address - Phone:203-576-5708
Mailing Address - Fax:203-367-8392
Practice Address - Street 1:2800 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-576-5708
Practice Address - Fax:203-367-8392
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039409208G00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001394098Medicaid
CT001394098Medicaid
H40389Medicare UPIN