1861599300 NPI number — SUDEEPTA A RAKHRA D.O.

Table of content: SUDEEPTA A RAKHRA D.O. (NPI 1861599300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861599300 NPI number — SUDEEPTA A RAKHRA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAKHRA
Provider First Name:
SUDEEPTA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BHARGAVE
Provider Other First Name:
SUDEEPTA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861599300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2968
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46515-2968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-296-3390
Provider Business Mailing Address Fax Number:
574-296-3391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 S NAPPANEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-2066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-296-3200
Provider Business Practice Location Address Fax Number:
574-296-3921
Provider Enumeration Date:
09/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036112090 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 02003431A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036112098 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200493650 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00171780 . This is a "R/R MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00713419 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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