Provider Demographics
NPI:1659458420
Name:RABURN, LOU A
Entity Type:Individual
Prefix:
First Name:LOU
Middle Name:A
Last Name:RABURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-3530
Mailing Address - Country:US
Mailing Address - Phone:409-735-2930
Mailing Address - Fax:409-735-4513
Practice Address - Street 1:1615 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:BRIDGE CITY
Practice Address - State:TX
Practice Address - Zip Code:77611-3530
Practice Address - Country:US
Practice Address - Phone:409-735-2930
Practice Address - Fax:409-735-4513
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
519608OtherBLUE CROSS BLUE SHIELD
TX1059700001Medicare ID - Type Unspecified