Healthcare Provider Details

I. General information

NPI: 1093712986
Provider Name (Legal Business Name): RAJI VENKAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAJI VENKATASUBRA M.D.

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 S EASTERN AVE STE 101
HENDERSON NV
89052-3908
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 702-616-5870
  • Fax: 702-616-5895
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8906
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: