Healthcare Provider Details

I. General information

NPI: 1255979779
Provider Name (Legal Business Name): RAJENDRA P KOIRALA, M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 BOARDMAN CANFIELD RD STE L1
YOUNGSTOWN OH
44512-4370
US

IV. Provider business mailing address

725 BOARDMAN CANFIELD RD STE L1
YOUNGSTOWN OH
44512-4370
US

V. Phone/Fax

Practice location:
  • Phone: 330-330-8655
  • Fax:
Mailing address:
  • Phone: 330-330-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: RHONDA HANNI
Title or Position: OFFICE MANAGER
Credential:
Phone: 330-330-8655