Provider Demographics
NPI:1033402631
Name:RAJAN, JESSEN A (MD)
Entity Type:Individual
Prefix:
First Name:JESSEN
Middle Name:A
Last Name:RAJAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11104 W AIRPORT BLVD STE 117
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-3043
Mailing Address - Country:US
Mailing Address - Phone:832-405-9984
Mailing Address - Fax:
Practice Address - Street 1:11104 W AIRPORT BLVD STE 117
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-3043
Practice Address - Country:US
Practice Address - Phone:832-405-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP4698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338010701Medicaid
TX8EK656OtherBLUE CROSS BLUE SHIELD
TX8FT444OtherBLUE CROSS BLUE SHIELD
TX254253ZSVEMedicare PIN
TX354253YQ64Medicare PIN