Healthcare Provider Details

I. General information

NPI: 1619003167
Provider Name (Legal Business Name): GORDON DAVID RAPHAEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 AUBURN AVE SUITE 202
BETHESDA MD
20814-2636
US

IV. Provider business mailing address

4915 AUBURN AVE SUITE 202
BETHESDA MD
20814-2636
US

V. Phone/Fax

Practice location:
  • Phone: 301-907-3442
  • Fax: 301-907-6835
Mailing address:
  • Phone: 301-907-3442
  • Fax: 301-907-6835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberD28918
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: