MEDICARE: NISHA RAJAGOPAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	38309	OK
2	208000000X	Pediatrics Physician	38309	OK

General Provider Information

NPI Number	:	1376159632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NISHA RAJAGOPAL

Provider Business Mailing Address
First Line	:	6152 S RICHMOND AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-1613
Country	:	US
Telephone Number	:	918-704-1585
Fax Number	:

Provider Business Practice Location Address
First Line	:	6152 S RICHMOND AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-1613
Country	:	US
Telephone Number	:	918-704-1585
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2020
Last Update Date	:	07/18/2024

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