Healthcare Provider Details

I. General information

NPI: 1518121169
Provider Name (Legal Business Name): RAJ CHAMPAK DEDHIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-2777
  • Fax: 215-662-4613
Mailing address:
  • Phone: 215-662-2777
  • Fax: 215-662-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberMD467165
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: