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General NPI Number Information
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NPI Number | 1124394572
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Entity Type | Individual
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Provider Name | SHYAM SAMPATH RAGHAVAN M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/30/2012
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Last Update Date | 08/08/2023
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Provider Practice Location Address
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Address Line | 1215 LEE ST
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22908-2205
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Country | US
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Telephone | 888-882-3990
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Fax | 434-243-6499
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Provider Business Mailing Address
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Address Line | PO BOX 110429
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City | AURORA
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State | CO
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Zip | 80042-0429
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZD0900X
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Taxonomy Name | Dermatopathology (Pathology) Physician
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License Number | 101269055
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 101269055
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | A127813
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 207ZD0900X
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Taxonomy Name | Dermatopathology (Pathology) Physician
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License Number | DR.0070540
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License Number State | CO
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