Provider Demographics
NPI:1700874898
Name:DOVLATYAN, RAIDA (MD)
Entity type:Individual
Prefix:
First Name:RAIDA
Middle Name:
Last Name:DOVLATYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:LEGAL DEPARTMENT
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:717-972-1100
Mailing Address - Fax:717-975-9981
Practice Address - Street 1:300 MARKET ST
Practice Address - Street 2:
Practice Address - City:SADDLE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07663-5309
Practice Address - Country:US
Practice Address - Phone:201-368-6019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05544300208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0050954Medicaid
NJ0050954Medicaid