Provider Demographics
NPI:1699025635
Name:ELYSE S RAFAL M D P C
Entity type:Organization
Organization Name:ELYSE S RAFAL M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELYSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAFAL
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:631-689-0300
Mailing Address - Street 1:2500 ROUTE 347
Mailing Address - Street 2:BUILDING 22A
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-689-0300
Mailing Address - Fax:631-689-1153
Practice Address - Street 1:2500 ROUTE 347
Practice Address - Street 2:BUILDING 22A
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-689-0300
Practice Address - Fax:631-689-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191543207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF50959Medicare UPIN
13U101Medicare Oscar/Certification