Provider Demographics
NPI:1841264413
Name:RAPHAELSON, MARC I (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:I
Last Name:RAPHAELSON
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 1:525K EAST MARKET ST
Mailing Address - Street 2:BOX 326
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:703-771-0274
Mailing Address - Fax:703-771-0276
Practice Address - Street 1:525K EAST MARKET ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-771-0274
Practice Address - Fax:703-771-0276
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2084N0400X2084N0400X
VA0101042614207RS0012X, 2084N0400X
WV14958207RS0012X
MDD0026660207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD13908 1300Medicaid
VA00X434M01Medicare Oscar/Certification
DCG01339M01Medicare Oscar/Certification
MD446M643FMedicare Oscar/Certification
MDB69911Medicare UPIN
MD13908 1300Medicaid