Healthcare Provider Details

I. General information

NPI: 1871601229
Provider Name (Legal Business Name): MUKUND C RAJA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 PHILIP BLVD SUITE 201
LAWRENCEVILLE GA
30046-8737
US

IV. Provider business mailing address

475 PHILIP BLVD SUITE 201
LAWRENCEVILLE GA
30046-8737
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-0220
  • Fax: 770-962-1566
Mailing address:
  • Phone: 770-962-0220
  • Fax: 770-962-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number026028
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: