Provider Demographics
NPI:1467490631
Name:RAO, SUPRASAD M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPRASAD
Middle Name:M
Last Name:RAO
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 1:808 S SILVERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4073
Mailing Address - Country:US
Mailing Address - Phone:505-807-1508
Mailing Address - Fax:
Practice Address - Street 1:710 BIRCHWOOD AVE
Practice Address - Street 2:STE. 201
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1720
Practice Address - Country:US
Practice Address - Phone:360-788-6870
Practice Address - Fax:360-788-6872
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061494A2084N0400X
WAMD601482082084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200821450Medicaid
KYG78874Medicare UPIN
IN200821450Medicaid