Provider Demographics
NPI:1083688642
Name:SASTRY, RAGHUNAND (MD)
Entity Type:Individual
Prefix:
First Name:RAGHUNAND
Middle Name:
Last Name:SASTRY
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 1:175 N JACKSON AVE
Mailing Address - Street 2:#205
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116
Mailing Address - Country:US
Mailing Address - Phone:408-272-2100
Mailing Address - Fax:408-259-4946
Practice Address - Street 1:175 N JACKSON AVE
Practice Address - Street 2:#205
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116
Practice Address - Country:US
Practice Address - Phone:408-272-2100
Practice Address - Fax:408-259-4946
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71904207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ02549ZOtherBLUE SHIELD OF CALIF
CA00A719040Medicaid
00A719040Medicare ID - Type Unspecified
CA00A719040Medicaid