Provider Demographics
NPI:1205815305
Name:RAJAN, PRABHA (MD)
Entity Type:Individual
Prefix:
First Name:PRABHA
Middle Name:
Last Name:RAJAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:(EMS BLDG., RM. 2209)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-3250
Mailing Address - Fax:708-216-2620
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(EMS BLDG., RM. 2209)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3250
Practice Address - Fax:708-216-2620
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36108172207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36108172Medicaid
IL36108172Medicaid
IL204144Medicare ID - Type Unspecified
G61494Medicare UPIN