Provider Demographics
NPI:1578680062
Name:VIDHUN, RAGHURAMAN R (MD)
Entity Type:Individual
Prefix:MR
First Name:RAGHURAMAN
Middle Name:R
Last Name:VIDHUN
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 1:455 CHASE PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3352
Mailing Address - Country:US
Mailing Address - Phone:203-573-1435
Mailing Address - Fax:203-755-7433
Practice Address - Street 1:455 CHASE PKWY
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3352
Practice Address - Country:US
Practice Address - Phone:203-573-1435
Practice Address - Fax:203-755-7433
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045393207RC0000X, 207RI0011X
NY236091207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPENDINGOtherRR MEDICARE
CT1578680062Medicaid
CT27-87690OtherUHC
CT7946957OtherAETNA
CT010045393CT02OtherANTHEM BCBS CT
CT3V1106OtherHEALTHNET/COMMERCIAL
CT27-87690OtherAMERICHOICE
CT001453935Medicaid
CT045393-7359OtherCONNECTICARE
CT407405OtherWELLCARE
CTD400039793Medicare PIN
CT045393-7359OtherCONNECTICARE