Healthcare Provider Details

I. General information

NPI: 1891991832
Provider Name (Legal Business Name): RAJARAM P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40124 HIGHWAY 27 SUITE 203
DAVENPORT FL
33837-5905
US

IV. Provider business mailing address

321 E ROBERTSON ST
BRANDON FL
33511-5253
US

V. Phone/Fax

Practice location:
  • Phone: 863-421-7626
  • Fax: 863-421-0886
Mailing address:
  • Phone: 813-685-2191
  • Fax: 813-689-8755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME0040960
License Number StateFL

VIII. Authorized Official

Name: DR. PERUMALSWAMY RAJARAM
Title or Position: PRESIDENT
Credential: M.D.,P.A.
Phone: 813-685-2191