Healthcare Provider Details

I. General information

NPI: 1003257130
Provider Name (Legal Business Name): RAJAGOPALAN RENGAN D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 MULBERRY ST
SCRANTON PA
18510-2369
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-969-0161
  • Fax: 570-969-0163
Mailing address:
  • Phone: 570-969-0161
  • Fax: 570-969-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberOS018758
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberOS018758
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS018758
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number25MB09747500
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: