Provider Demographics
NPI:1003202946
Name:DODDAMANI, RAJIV
Entity Type:Individual
Prefix:
First Name:RAJIV
Middle Name:
Last Name:DODDAMANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MCAULEY DR
Mailing Address - Street 2:3009
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-0995
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE 4001
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-834-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310930207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program