Provider Demographics
NPI:1124039144
Name:RAJU, KANTHI (DO)
Entity Type:Individual
Prefix:DR
First Name:KANTHI
Middle Name:
Last Name:RAJU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 LAKESIDE BLVD STE 225E
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4302
Mailing Address - Country:US
Mailing Address - Phone:972-907-5230
Mailing Address - Fax:972-907-5231
Practice Address - Street 1:2150 LAKESIDE BLVD STE 225E
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082
Practice Address - Country:US
Practice Address - Phone:972-907-5230
Practice Address - Fax:972-907-5231
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK19052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609942Medicare UPIN
TXH08134Medicare UPIN