Provider Demographics
NPI:1821095860
Name:PATLOLA, RAGHOTHAM REDDY (MD)
Entity Type:Individual
Prefix:
First Name:RAGHOTHAM
Middle Name:REDDY
Last Name:PATLOLA
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 70
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:LA
Mailing Address - Zip Code:70558
Mailing Address - Country:US
Mailing Address - Phone:337-456-6523
Mailing Address - Fax:337-456-6521
Practice Address - Street 1:4811 AMBASSADOR CAFFERY PARKWAY
Practice Address - Street 2:SUITE 401A
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-456-6523
Practice Address - Fax:337-456-6521
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15607R207RC0000X, 207RI0011X
MS23173207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1349844Medicaid
LAP00158213OtherRR MEDICARE
LA4J002Medicare PIN
LAP00158213OtherRR MEDICARE