Provider Demographics
NPI:1417327586
Name:RAGHAVAN, RENITHA
Entity Type:Individual
Prefix:
First Name:RENITHA
Middle Name:
Last Name:RAGHAVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENITHA
Other - Middle Name:
Other - Last Name:RAGHAVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1215 LEE ST
Mailing Address - Street 2:800394
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-924-5306
Mailing Address - Fax:434-982-1064
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:800394
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-924-5306
Practice Address - Fax:434-982-1064
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116028744390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program