Provider Demographics
NPI:1861980872
Name:GUTMAN, RAFFY (MD)
Entity type:Individual
Prefix:
First Name:RAFFY
Middle Name:
Last Name:GUTMAN
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 1:2 MEMORIAL DR STE 220
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6723
Mailing Address - Country:US
Mailing Address - Phone:618-474-1723
Mailing Address - Fax:
Practice Address - Street 1:2 MEMORIAL DR STE 220
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6723
Practice Address - Country:US
Practice Address - Phone:618-474-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2023-02-08
Deactivation Date:2018-11-29
Deactivation Code:
Reactivation Date:2018-12-05
Provider Licenses
StateLicense IDTaxonomies
IL036154406207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine