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General NPI Number Information
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NPI Number | 1528008414
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Entity Type | Individual
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Provider Name | RAJAGOPALA SWAMINATHAN MD
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Gender | Male
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Dates
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Enumeration Date | 06/08/2006
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 3024 E EMPIRE ST STE EANDF
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City | BLOOMINGTON
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State | IL
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Zip | 61704-5402
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Country | US
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Telephone | 309-451-3376
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Fax | 309-452-3376
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Provider Business Mailing Address
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Address Line | 3024 E EMPIRE ST STE E
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City | BLOOMINGTON
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State | IL
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Zip | 61704-5402
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Country | US
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Telephone | 309-451-3376
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Fax | 309-452-3376
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 036052561
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License Number State | IL
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