Healthcare Provider Details

I. General information

NPI: 1326326968
Provider Name (Legal Business Name): SHINE KOCHUKUNJU RAJU M.B.B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCONN HEALTH CTR 263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

83 LEAFWOOD LN APT 220
GROTON CT
06340-6250
US

V. Phone/Fax

Practice location:
  • Phone: 516-943-2400
  • Fax:
Mailing address:
  • Phone: 516-943-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: