Provider Demographics
NPI:1780737510
Name:RAGHAVAN, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:RAGHAVAN
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 1:8324 WESTOVER CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9472
Mailing Address - Country:US
Mailing Address - Phone:502-327-9703
Mailing Address - Fax:502-327-9798
Practice Address - Street 1:9720 PARK PLAZA AVE UNIT 202
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2290
Practice Address - Country:US
Practice Address - Phone:502-327-9703
Practice Address - Fax:502-327-9798
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY345552080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYG24963Medicare UPIN