Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | F8987 | TX |
NPI | 1073570032 |
---|---|
Provider Name | Dr. Puthalath Koroth Raghuprasad |
First Address | Odessa, TX 79761-4902 |
Second Address | Odessa, TX 79761-4902 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2006 |
Last Update Date | 23/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0357949-01 | (05) | TX |
B25737 | (02) | TX |