Provider Demographics
NPI:1124073630
Name:KEVORKIAN, RAFI THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:RAFI
Middle Name:THOMAS
Last Name:KEVORKIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:522 N NEW BALLAS RD STE 317
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6840
Mailing Address - Country:US
Mailing Address - Phone:636-634-5865
Mailing Address - Fax:
Practice Address - Street 1:522 N NEW BALLAS RD STE 317
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6840
Practice Address - Country:US
Practice Address - Phone:636-634-5865
Practice Address - Fax:636-688-8317
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108134207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00413101OtherRR MEDICARE
MO205037823Medicaid
MOG97365Medicare UPIN
MOP00413101OtherRR MEDICARE