Provider Demographics
NPI:1992749121
Name:DJEVALIKIAN, RAFFI (MD)
Entity type:Individual
Prefix:
First Name:RAFFI
Middle Name:
Last Name:DJEVALIKIAN
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:PO BOX 1269
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-1269
Mailing Address - Country:US
Mailing Address - Phone:918-650-1301
Mailing Address - Fax:918-650-0568
Practice Address - Street 1:DEWEY BARTLETT & MAIN
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437
Practice Address - Country:US
Practice Address - Phone:918-650-1301
Practice Address - Fax:918-650-0568
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK22166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKJ45631Medicare UPIN