1750667416 NPI number — RAGHU V DEVABHAKTUNI MDPA

Table of content: (NPI 1750667416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750667416 NPI number — RAGHU V DEVABHAKTUNI MDPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAGHU V DEVABHAKTUNI MDPA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750667416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13908 LAKESHORE BLVD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34667-1492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-869-3227
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13908 LAKESHORE BLVD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34667-1492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-869-3227
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DEVABHAKTUNI
Authorized Official First Name:
RAGHU
Authorized Official Middle Name:
V
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
727-869-3227

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  ME 61245 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016652500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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