Provider Demographics
NPI:1124394572
Name:RAGHAVAN, SHYAM SAMPATH (MD)
Entity Type:Individual
Prefix:
First Name:SHYAM
Middle Name:SAMPATH
Last Name:RAGHAVAN
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:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-2205
Practice Address - Country:US
Practice Address - Phone:888-882-3990
Practice Address - Fax:434-243-6499
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101269055207ZD0900X, 207ZP0102X
CAA127813208200000X
CODR.0070540207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery