Provider Demographics
NPI:1073659629
Name:AMOONA, RAPHAEL
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:AMOONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1573 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HEWLETT,
Mailing Address - State:NY
Mailing Address - Zip Code:11557
Mailing Address - Country:US
Mailing Address - Phone:516-374-3322
Mailing Address - Fax:516-374-0944
Practice Address - Street 1:1573 BROADWAY
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1428
Practice Address - Country:US
Practice Address - Phone:516-374-3322
Practice Address - Fax:516-374-0944
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1132772080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB18707Medicare UPIN