Provider Demographics
NPI:1477507531
Name:HIGGINBOTHAM, RAPHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:JOHN
Last Name:HIGGINBOTHAM
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 1:5018 VIDRINE RD
Mailing Address - Street 2:
Mailing Address - City:VILLE PLATTE
Mailing Address - State:LA
Mailing Address - Zip Code:70586-8707
Mailing Address - Country:US
Mailing Address - Phone:504-473-8079
Mailing Address - Fax:
Practice Address - Street 1:927 E PRUDHOMME ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-8240
Practice Address - Country:US
Practice Address - Phone:337-594-8381
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025644207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA04333Medicaid