Provider Demographics
NPI:1578613543
Name:BOOTHPUR, RAGHAVENDER (MD)
Entity Type:Individual
Prefix:DR
First Name:RAGHAVENDER
Middle Name:
Last Name:BOOTHPUR
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 1:1525 PLUMAS CT
Mailing Address - Street 2:STE C
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-2971
Mailing Address - Country:US
Mailing Address - Phone:530-822-5575
Mailing Address - Fax:530-822-5585
Practice Address - Street 1:1525 PLUMAS CT
Practice Address - Street 2:STE C
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-2971
Practice Address - Country:US
Practice Address - Phone:530-822-5575
Practice Address - Fax:530-822-5585
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117765208M00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid
CAPENDINGMedicare PIN