Provider Demographics
NPI:1851769665
Name:RAGHURAM, VAISHNAVI
Entity Type:Individual
Prefix:
First Name:VAISHNAVI
Middle Name:
Last Name:RAGHURAM
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 1:808 N FRANKLIN ST
Mailing Address - Street 2:APT 1515
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3859
Mailing Address - Country:US
Mailing Address - Phone:617-510-3675
Mailing Address - Fax:
Practice Address - Street 1:10224 E ADAMO DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-2663
Practice Address - Country:US
Practice Address - Phone:813-643-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 5131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist