Provider Demographics
NPI:1164699906
Name:RAGHAVAN, KARTHIK (MD)
Entity Type:Individual
Prefix:
First Name:KARTHIK
Middle Name:
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 1:2320 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1303
Mailing Address - Country:US
Mailing Address - Phone:602-258-9900
Mailing Address - Fax:602-258-9904
Practice Address - Street 1:5700 W OLIVE AVE STE 106
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-3147
Practice Address - Country:US
Practice Address - Phone:623-377-7011
Practice Address - Fax:623-344-8353
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49344208600000X
NY269619208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ972039Medicaid
NY03244355Medicaid