Provider Demographics
NPI:1548305444
Name:RAFAELOFF, PARVANEH (MD)
Entity type:Individual
Prefix:MRS
First Name:PARVANEH
Middle Name:
Last Name:RAFAELOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 S GLENDALE AVE
Mailing Address - Street 2:#308
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2405
Mailing Address - Country:US
Mailing Address - Phone:818-265-1255
Mailing Address - Fax:818-265-1283
Practice Address - Street 1:1030 S GLENDALE AVE
Practice Address - Street 2:#308
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2405
Practice Address - Country:US
Practice Address - Phone:818-265-1255
Practice Address - Fax:818-265-1283
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52350208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52350Medicaid
CAA52350Medicaid