Provider Demographics
NPI:1659329480
Name:RAGHU, DEEPAK RAO (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:RAO
Last Name:RAGHU
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:11995 SINGLETREE LN STE 500
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5349
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050139032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207504408Medicaid
MOP00287574Medicare PIN
MO935140635Medicare PIN
I40783Medicare UPIN
MO207504408Medicaid
MO935145236Medicare PIN