Provider Demographics
NPI:1326237322
Name:RAGHAVAN, CHIDAMBARAM (MD)
Entity Type:Individual
Prefix:
First Name:CHIDAMBARAM
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 1:5041 DALLAS HWY BLDG 2
Mailing Address - Street 2:SUITE E
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6458
Mailing Address - Country:US
Mailing Address - Phone:770-218-1880
Mailing Address - Fax:770-218-1088
Practice Address - Street 1:5041 DALLAS HWY BLDG 2
Practice Address - Street 2:SUITE E
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6458
Practice Address - Country:US
Practice Address - Phone:770-218-1880
Practice Address - Fax:770-218-1088
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00626117AMedicaid
GA617437OtherBLUE CROSS BLUE SHIELD
GA0400005OtherUNITED HEALTHCARE
GA0400005OtherUNITED HEALTHCARE
GA11BDMWQMedicare PIN