Provider Demographics
NPI:1144387408
Name:RAPHAEL, ROBERT IAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:IAN
Last Name:RAPHAEL
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 1:3505 BROADWAY FL 14
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5798
Mailing Address - Country:US
Mailing Address - Phone:510-752-1114
Mailing Address - Fax:
Practice Address - Street 1:3505 BROADWAY FL 14
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5798
Practice Address - Country:US
Practice Address - Phone:510-752-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA813182080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A813180Medicaid
CA00A813180Medicare ID - Type Unspecified
CAI22076Medicare UPIN