Provider Demographics
NPI:1447479472
Name:RAJ, KELLY A (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:RAJ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BOGHOSIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:18200 LORAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-5605
Mailing Address - Country:US
Mailing Address - Phone:216-476-7088
Mailing Address - Fax:216-476-7604
Practice Address - Street 1:18200 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5605
Practice Address - Country:US
Practice Address - Phone:216-476-7088
Practice Address - Fax:216-476-7604
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-009326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000595029OtherANTHEM
OH2932527Medicaid
OHP00759713OtherRAILROAD MEDICARE
OHP00759713OtherRAILROAD MEDICARE