Provider Demographics
NPI:1932335064
Name:RAGHEB, JACK A (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:RAGHEB
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11702 IBSEN DR
Mailing Address - Street 2:
Mailing Address - City:N BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3724
Mailing Address - Country:US
Mailing Address - Phone:301-435-4566
Mailing Address - Fax:
Practice Address - Street 1:10 CENTER DR
Practice Address - Street 2:MSC-1857
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-0001
Practice Address - Country:US
Practice Address - Phone:301-435-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0041560207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics