Provider Demographics
NPI:1346248127
Name:RAJU, VADREVU K (MD)
Entity Type:Individual
Prefix:DR
First Name:VADREVU
Middle Name:K
Last Name:RAJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1255 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2738
Mailing Address - Country:US
Mailing Address - Phone:304-598-3301
Mailing Address - Fax:304-225-0516
Practice Address - Street 1:1255 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2738
Practice Address - Country:US
Practice Address - Phone:304-598-3301
Practice Address - Fax:304-225-0516
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11294207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0096681000Medicaid
WV0007123000Medicaid
WVD49380Medicare UPIN