Healthcare Provider Details

I. General information

NPI: 1750896858
Provider Name (Legal Business Name): TREVOR ROBERT RAFFERTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 06/27/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-2604
US

IV. Provider business mailing address

16278 PABLO CREEK LN
FONTANA CA
92336-5826
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License NumberA180392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: