Provider Demographics
NPI:1447538079
Name:KONANUR VENKATARAM, RAGHU
Entity type:Individual
Prefix:
First Name:RAGHU
Middle Name:
Last Name:KONANUR VENKATARAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19950 RINALDI ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326
Practice Address - Country:US
Practice Address - Phone:818-271-2400
Practice Address - Fax:818-271-2401
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA147233207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification