Provider Demographics
NPI:1053512814
Name:RAJU, VENKEDESH (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKEDESH
Middle Name:
Last Name:RAJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 NE GLEN OAK AVE
Mailing Address - Street 2:204 STONECREST APARTMENTS
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3285
Mailing Address - Country:US
Mailing Address - Phone:309-648-3184
Mailing Address - Fax:
Practice Address - Street 1:1001 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6427
Practice Address - Country:US
Practice Address - Phone:641-682-7511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125050775208000000X
IAMD-42748208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP PTAN
IL809840016Medicare PIN