Provider Demographics
NPI:1841308830
Name:RAIKAR, BAO-LAN (MD)
Entity type:Individual
Prefix:
First Name:BAO-LAN
Middle Name:
Last Name:RAIKAR
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 1:3820 NORTHDALE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1893
Mailing Address - Country:US
Mailing Address - Phone:800-991-6117
Mailing Address - Fax:888-812-8191
Practice Address - Street 1:200 S GREENLEAF ST STE E
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3398
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:888-812-8191
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL39327-20202K00000X, 208600000X
CAA69461208600000X
MN35479208600000X
WI39327208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1841308830Medicaid