Healthcare Provider Details

I. General information

NPI: 1306308168
Provider Name (Legal Business Name): MICHAEL ADAM RAGHUNATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MEDICAL PLZ STE 302
GLEN COVE NY
11542-2101
US

IV. Provider business mailing address

10 MEDICAL PLZ STE 302
GLEN COVE NY
11542-2101
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-7900
  • Fax:
Mailing address:
  • Phone: 516-674-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number318399
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: