Provider Demographics
NPI:1467418749
Name:RAGHAVAN, RHODORA AMALIAN (MD)
Entity Type:Individual
Prefix:
First Name:RHODORA
Middle Name:AMALIAN
Last Name:RAGHAVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RHODORA
Other - Middle Name:AMALIAN
Other - Last Name:LACERNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 23410
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72221-3410
Mailing Address - Country:US
Mailing Address - Phone:501-224-1690
Mailing Address - Fax:
Practice Address - Street 1:10301 KANIS RD STE 1
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6205
Practice Address - Country:US
Practice Address - Phone:501-562-4838
Practice Address - Fax:501-562-1958
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BM746OtherBLUE CROSS BLUE SHIELD
AR1592123001OtherMEDICAID
AR5M746OtherMEDICARE
ARI02290OtherUPIN
AR159213001Medicaid
ARI02290OtherUPIN