Provider Demographics
NPI:1134478738
Name:TANIKELLA, RAJASEKHAR (MD)
Entity Type:Individual
Prefix:
First Name:RAJASEKHAR
Middle Name:
Last Name:TANIKELLA
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 1:120 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-9238
Mailing Address - Country:US
Mailing Address - Phone:417-533-6100
Mailing Address - Fax:
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9238
Practice Address - Country:US
Practice Address - Phone:417-533-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027806208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid