Provider Demographics
NPI:1073570032
Name:RAGHUPRASAD, PUTHALATH KOROTH (MD)
Entity Type:Individual
Prefix:DR
First Name:PUTHALATH
Middle Name:KOROTH
Last Name:RAGHUPRASAD
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 1:2400 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4902
Mailing Address - Country:US
Mailing Address - Phone:432-332-5533
Mailing Address - Fax:432-580-5533
Practice Address - Street 1:2400 E 8TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4902
Practice Address - Country:US
Practice Address - Phone:432-332-5533
Practice Address - Fax:432-580-5533
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8987207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0357949-01Medicaid
TX0357949-01Medicaid
TXB25737Medicare UPIN