Provider Demographics
NPI:1770539801
Name:RAPHAEL, ALLEN TERENCE (DPM)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:TERENCE
Last Name:RAPHAEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CIRCLE 75 PKWY. SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3084
Mailing Address - Country:US
Mailing Address - Phone:678-426-2171
Mailing Address - Fax:404-446-1957
Practice Address - Street 1:3200 HIGHLANDS PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5196
Practice Address - Country:US
Practice Address - Phone:770-319-5502
Practice Address - Fax:770-434-9010
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001050213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52212173-001OtherBC/BS, SMYRNA
GA761921467PMedicaid
GA761921467GMedicaid
GA52212173-002OtherBC/BS DOUGLASVILLE
GA761921467AMedicaid
GA946888OtherBLUE CROSS BLUE SHIELD GA
GA5284933OtherCIGNA
GA761921467JMedicaid
GA581994261OtherGREAT WEST HEALTHCARE
GA761921467CMedicaid
GA761921467AMedicaid
GA52212173-002OtherBC/BS DOUGLASVILLE
GA52212173-001OtherBC/BS, SMYRNA
GA761921467GMedicaid