Provider Demographics
NPI:1144804329
Name:RAJAN, NIVEDHA POTHAKA
Entity Type:Individual
Prefix:
First Name:NIVEDHA
Middle Name:POTHAKA
Last Name:RAJAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36808 OAK ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4817
Mailing Address - Country:US
Mailing Address - Phone:510-203-9392
Mailing Address - Fax:
Practice Address - Street 1:36808 OAK ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4817
Practice Address - Country:US
Practice Address - Phone:510-203-9392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2074566666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty