Provider Demographics
NPI:1164403705
Name:RAJ, DHARAM (MD)
Entity Type:Individual
Prefix:
First Name:DHARAM
Middle Name:
Last Name:RAJ
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 1:1251 KEM RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952
Mailing Address - Country:US
Mailing Address - Phone:765-662-8696
Mailing Address - Fax:765-662-8738
Practice Address - Street 1:1251 KEM RD
Practice Address - Street 2:SUITE B
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952
Practice Address - Country:US
Practice Address - Phone:765-662-8696
Practice Address - Fax:765-662-8738
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027274A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000362238OtherANTHEM BCBS
IN000000362238OtherANTHEM BCBS