Healthcare Provider Details

I. General information

NPI: 1073554838
Provider Name (Legal Business Name): RAFAEL ENUKASHVILI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 KILMER DRIVE BLDG 2 SUITE C
MORGANVILLE NJ
07751-1568
US

IV. Provider business mailing address

21 KILMER DRIVE BLDG 2 SUITE C
MORGANVILLE NJ
07751-1568
US

V. Phone/Fax

Practice location:
  • Phone: 732-617-2988
  • Fax: 732-617-2987
Mailing address:
  • Phone: 732-617-2988
  • Fax: 732-617-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA064386
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: