Provider Demographics
NPI:1194170324
Name:ROXANA RAICU, M.D.
Entity type:Organization
Organization Name:ROXANA RAICU, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANA
Authorized Official - Middle Name:G
Authorized Official - Last Name:RAICU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-603-4480
Mailing Address - Street 1:10 CALIENTE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9167
Mailing Address - Country:US
Mailing Address - Phone:505-603-4480
Mailing Address - Fax:505-807-0285
Practice Address - Street 1:2204 BROTHERS RD
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6975
Practice Address - Country:US
Practice Address - Phone:505-603-4480
Practice Address - Fax:505-807-0285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0100102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty