Healthcare Provider Details

I. General information

NPI: 1689771016
Provider Name (Legal Business Name): RAJA S MAHIDHARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 ST FRANCIS WAY STE 200
LAFAYETTE IN
47905-4940
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-775-2800
  • Fax:
Mailing address:
  • Phone: 317-528-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01070300A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01070300A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: