Provider Demographics
NPI:1871601229
Name:RAJA, MUKUND C (MD)
Entity type:Individual
Prefix:
First Name:MUKUND
Middle Name:C
Last Name:RAJA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:475 PHILIP BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8737
Mailing Address - Country:US
Mailing Address - Phone:770-962-0220
Mailing Address - Fax:770-962-1566
Practice Address - Street 1:475 PHILIP BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8737
Practice Address - Country:US
Practice Address - Phone:770-962-0220
Practice Address - Fax:770-962-1566
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2014-09-03
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Provider Licenses
StateLicense IDTaxonomies
GA026028207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00302541AMedicaid
GA00302541AMedicaid