Provider Demographics
NPI:1194768994
Name:RAFF, JOHN BOURKE (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BOURKE
Last Name:RAFF
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 1:4500 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2515
Mailing Address - Country:US
Mailing Address - Phone:601-249-4282
Mailing Address - Fax:601-249-4852
Practice Address - Street 1:1506 ASTON AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2735
Practice Address - Country:US
Practice Address - Phone:601-249-4282
Practice Address - Fax:601-249-4852
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD025787207X00000X
MS19880207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08585290Medicaid
315777YQVYMedicare PIN
MS08585290Medicaid