Healthcare Provider Details

I. General information

NPI: 1558360636
Provider Name (Legal Business Name): CHARLES EDWARD RAFTERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1579 STRAITS TPKE
MIDDLEBURY CT
06762-1835
US

IV. Provider business mailing address

1579 STRAITS TPKE
MIDDLEBURY CT
06762-1835
US

V. Phone/Fax

Practice location:
  • Phone: 203-758-2003
  • Fax: 203-758-2144
Mailing address:
  • Phone: 203-758-2003
  • Fax: 203-758-2144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number041372
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: