Provider Demographics
NPI:1861599300
Name:RAKHRA, SUDEEPTA A (DO)
Entity type:Individual
Prefix:
First Name:SUDEEPTA
Middle Name:A
Last Name:RAKHRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUDEEPTA
Other - Middle Name:A
Other - Last Name:BHARGAVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3390
Mailing Address - Fax:574-296-3391
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3200
Practice Address - Fax:574-296-3921
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112090207Q00000X
IN02003431A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112098Medicaid
IN200493650Medicaid
P00171780OtherR/R MEDICARE
INP00713419OtherRR MEDICARE
INP00713419OtherRR MEDICARE
P00171780OtherR/R MEDICARE
ILK10922Medicare ID - Type Unspecified