Provider Demographics
NPI:1518962638
Name:ALLA, RAGHAVARAO (MD)
Entity Type:Individual
Prefix:DR
First Name:RAGHAVARAO
Middle Name:
Last Name:ALLA
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 1:2495 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-473-0010
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06102R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1335096Medicaid
LAB62354Medicare UPIN
LA50381Medicare ID - Type Unspecified