Provider Demographics
NPI:1679788392
Name:SUDHARTO, RATIH B (MD)
Entity Type:Individual
Prefix:DR
First Name:RATIH
Middle Name:B
Last Name:SUDHARTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4518
Practice Address - Country:US
Practice Address - Phone:703-237-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550525724007OtherTRICARE CHAMPUS
WV3810009609Medicaid
B682OtherBLUE CROSS BLUE SHIELD
WV1071992OtherWORKERS COMPENSATION
WV7372621Medicare PIN
WV1071992OtherWORKERS COMPENSATION
VA562867Medicare PIN