Provider Demographics
NPI:1205835725
Name:AGADA, RAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:AGADA
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 1:801 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-5149
Mailing Address - Country:US
Mailing Address - Phone:804-862-5991
Mailing Address - Fax:
Practice Address - Street 1:801 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5149
Practice Address - Country:US
Practice Address - Phone:804-862-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101840585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205835725Medicaid
VA1205835725OtherBCBS
H09245Medicare PIN
VA1205835725Medicaid
00X600R02Medicare PIN