Healthcare Provider Details

I. General information

NPI: 1124051065
Provider Name (Legal Business Name): RAGHU IDUPUGANTI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 1ST ST
MINEOLA NY
11501-3957
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-2216
  • Fax:
Mailing address:
  • Phone: 800-242-1131
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number238871
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: