=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861460214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAJA KOLISETTI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2006
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 W MAIN ST UNIT 333
-----------------------------------------------------
City | BATAVIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14021-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-703-0101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 333
-----------------------------------------------------
City | BATAVIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14021-0333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-703-0101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | U4548
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 185959
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------