Healthcare Provider Details

I. General information

NPI: 1104446467
Provider Name (Legal Business Name): SURESH RAJA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 GREEN BAYBERRY DR
PALM BEACH GARDENS FL
33418-1510
US

IV. Provider business mailing address

11104 GREEN BAYBERRY DR
PALM BEACH GARDENS FL
33418-1510
US

V. Phone/Fax

Practice location:
  • Phone: 561-767-0721
  • Fax:
Mailing address:
  • Phone: 561-767-0721
  • Fax: 561-429-6223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SURESH RAJAMANICKAM
Title or Position: DIRECT OWNER
Credential: MD
Phone: 561-767-0721