Healthcare Provider Details

I. General information

NPI: 1255081691
Provider Name (Legal Business Name): RAGHURAM SRINIVASAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 W LEXINGTON STE 100
CINCINNATI OH
45212-3667
US

IV. Provider business mailing address

407 RACE ST APT 1325
CINCINNATI OH
45202-3771
US

V. Phone/Fax

Practice location:
  • Phone: 513-977-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number011430
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: