Healthcare Provider Details

I. General information

NPI: 1104829407
Provider Name (Legal Business Name): RAJESWARA R. PATCHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 E MAIN ST
HUNTINGTON NY
11743-2948
US

IV. Provider business mailing address

172 E MAIN ST
HUNTINGTON NY
11743-2948
US

V. Phone/Fax

Practice location:
  • Phone: 631-385-0022
  • Fax: 631-385-0896
Mailing address:
  • Phone: 631-385-0022
  • Fax: 631-385-0896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number147275
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number147275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: