Provider Demographics
NPI:1740268598
Name:DELOATCH, RAVEN LIONEL (MD)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:LIONEL
Last Name:DELOATCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-0640
Mailing Address - Country:US
Mailing Address - Phone:252-536-5791
Mailing Address - Fax:252-536-5444
Practice Address - Street 1:9425 NC HIGHWAY 305
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NC
Practice Address - Zip Code:27845-9679
Practice Address - Country:US
Practice Address - Phone:252-534-1661
Practice Address - Fax:252-534-2841
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC31478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28324OtherBLUE CROSS BLUE SHIELD #
NC110147756OtherRAILROAD MEDICARE #
NC0454365OtherUNITED HEALTH CARE #
NCD2792OtherMEDCOST LLC PROVIDER #
NC31478OtherNC MEDICAL LICENSE #
NC7928324Medicaid
NC112536OtherANTHEM SERVICES PROVIDER#
NC289354OtherMAMSI PROVIDER #
NC289354OtherMAMSI PROVIDER #
NC31478OtherNC MEDICAL LICENSE #
NCC87736Medicare UPIN