Healthcare Provider Details

I. General information

NPI: 1689025512
Provider Name (Legal Business Name): RAHUL RAGHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 NORRIS CANYON RD STE 200
SAN RAMON CA
94583-5440
US

IV. Provider business mailing address

5801 NORRIS CANYON RD STE 200
SAN RAMON CA
94583-5440
US

V. Phone/Fax

Practice location:
  • Phone: 925-830-8823
  • Fax:
Mailing address:
  • Phone: 925-830-8823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD470401
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD470401
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberA174238
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: