Healthcare Provider Details

I. General information

NPI: 1366066698
Provider Name (Legal Business Name): RAAJ GHOSAL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 S EASON BLVD STE 101
TUPELO MS
38801-6586
US

IV. Provider business mailing address

PO BOX 1635
MONTGOMERY TX
77356-1635
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-6609
  • Fax: 662-377-6614
Mailing address:
  • Phone: 251-509-8409
  • Fax: 251-509-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29327
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: