Healthcare Provider Details

I. General information

NPI: 1083961528
Provider Name (Legal Business Name): RENJU VECHURETTU RAJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE NEOPLASTIC DISEASES HOSPITALIST
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE NEOPLASTIC DISEASES HOSPITALIST
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-6800
  • Fax: 414-805-6805
Mailing address:
  • Phone: 414-805-6800
  • Fax: 414-805-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40893
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number62630
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: