Provider Demographics
NPI:1104829407
Name:PATCHA, RAJESWARA R (MD)
Entity Type:Individual
Prefix:
First Name:RAJESWARA
Middle Name:R
Last Name:PATCHA
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 1:172 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2948
Mailing Address - Country:US
Mailing Address - Phone:631-385-0022
Mailing Address - Fax:631-385-0896
Practice Address - Street 1:172 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2948
Practice Address - Country:US
Practice Address - Phone:631-385-0022
Practice Address - Fax:631-385-0896
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147275207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00767395Medicaid
NYB79934Medicare UPIN
NY94A901Medicare PIN