MEDICARE: DR. SAMUEL JOHN N RAJARATNAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	A51207	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VERD214	OTHER	CA	STAFF#

General Provider Information

NPI Number	:	1427103522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL JOHN N RAJARATNAM MD

Provider Business Mailing Address
First Line	:	23509 RIDGE LINE RD
Second Line	:
City	:	DIAMOND BAR
State	:	CA
Zip	:	91765-3008
Country	:	US
Telephone Number	:	714-553-4592
Fax Number	:	714-841-6775

Provider Business Practice Location Address
First Line	:	16152 BEACH BLVD STE 200
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3869
Country	:	US
Telephone Number	:	714-841-6772
Fax Number	:	714-841-6775

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	04/11/2017

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