Provider Demographics
NPI:1164609491
Name:TADIKAMALLA, RAGHU R (MD)
Entity Type:Individual
Prefix:
First Name:RAGHU
Middle Name:R
Last Name:TADIKAMALLA
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 1:4815 LIBERTY AVE STE 156
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-578-4230
Mailing Address - Fax:412-578-4201
Practice Address - Street 1:4815 LIBERTY AVE STE 156
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-578-4230
Practice Address - Fax:412-578-4201
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242949207RC0000X
PAMD426491207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164609491Medicaid
VAC10251Medicare UPIN
DC003691M22Medicare PIN
VAMC10237Medicare PIN
VAP00641911Medicare PIN