Provider Demographics
NPI:1417939885
Name:DASARI, RAGHURAM (MD)
Entity Type:Individual
Prefix:
First Name:RAGHURAM
Middle Name:
Last Name:DASARI
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 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:216-364-3610
Practice Address - Street 1:85 E US HIGHWAY 6 STE 300
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8948
Practice Address - Country:US
Practice Address - Phone:219-983-6300
Practice Address - Fax:219-983-6080
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060158A207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000496942OtherBLUE CROSS BLUE SHIELD IN
P00369368OtherRAILROAD MEDICARE
90000561OtherBLUE SHIELD OF IL
IN200506520Medicaid
000000496942OtherBLUE CROSS BLUE SHIELD IN