Basic Information
| Provider Information | |||||||||
| NPI: | 1104812999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAGHU-OBLESHWAR | ||||||||
| FirstName: | BALAJI | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10051 5TH ST N STE 200 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337022211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10051 5TH ST N STE 200 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337022211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | 8135148891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME110870 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 015454700 | 05 | FL | MEDICAID | IH298Y | 01 | FL | MEDICARE PIN | OTHER |