Provider Demographics
NPI:1730155029
Name:KIEVAL, RAPHAEL I (MD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:I
Last Name:KIEVAL
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 1:1351 MAIN ST
Mailing Address - Street 2:REAR
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7153
Mailing Address - Country:US
Mailing Address - Phone:508-587-4112
Mailing Address - Fax:508-583-6810
Practice Address - Street 1:1351 MAIN ST
Practice Address - Street 2:REAR
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7153
Practice Address - Country:US
Practice Address - Phone:508-587-4112
Practice Address - Fax:508-583-6810
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52349207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3029042Medicaid
A59229Medicare UPIN
J06952Medicare ID - Type Unspecified