Provider Demographics
NPI:1265444608
Name:RAGHAVAN, SRINIVASAN (MD)
Entity Type:Individual
Prefix:MR
First Name:SRINIVASAN
Middle Name:
Last Name:RAGHAVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:STE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-543-5942
Mailing Address - Fax:314-543-5947
Practice Address - Street 1:12700 SOUTHFORK ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-543-5942
Practice Address - Fax:314-543-5947
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2000143921207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204965008Medicaid
MO204965008Medicaid
MO918730723Medicare PIN