Basic Information
| Provider Information | |||||||||
| NPI: | 1184886731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAFATI | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BRAVE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRAVE | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2100 TROY RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620252595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186568888 | ||||||||
| FaxNumber: | 6186568920 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 TROY RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620252595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186568888 | ||||||||
| FaxNumber: | 6186568920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2008017085 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0460100111 | 05 | IL | MEDICAID | 1184886731 | 05 | MO | MEDICAID |