Healthcare Provider Details

I. General information

NPI: 1487184255
Provider Name (Legal Business Name): MAYURESH RAJARATNAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 CENTRAL AVE NW
EAST GRAND FORKS MN
56721-1917
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-773-6800
  • Fax: 218-773-6861
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRL14662
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17087
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: