Provider Demographics
NPI:1083497085
Name:SUPRA, RAJESH
Entity Type:Individual
Prefix:
First Name:RAJESH
Middle Name:
Last Name:SUPRA
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 1:2800 ROMORA BAY DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-7921
Mailing Address - Country:US
Mailing Address - Phone:925-705-0203
Mailing Address - Fax:
Practice Address - Street 1:1400 FLORIDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4446
Practice Address - Country:US
Practice Address - Phone:209-573-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program