Basic Information
| Provider Information | |||||||||
| NPI: | 1154495125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAIKAR | ||||||||
| FirstName: | SOUBRATA | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1439 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027218895 | ||||||||
| FaxNumber: | 4027216663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1439 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027218895 | ||||||||
| FaxNumber: | 4027216663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 21157 | NE | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 21157 | NE | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10025199800 | 05 | NE | MEDICAID |