Provider Demographics
NPI:1215019328
Name:MADDIPOTI, RAJA C (MD)
Entity Type:Individual
Prefix:
First Name:RAJA
Middle Name:C
Last Name:MADDIPOTI
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:PO BOX 26067
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84126-0067
Mailing Address - Country:US
Mailing Address - Phone:239-624-0400
Mailing Address - Fax:239-624-0464
Practice Address - Street 1:625 9TH ST N STE 201
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-8143
Practice Address - Country:US
Practice Address - Phone:239-261-2000
Practice Address - Fax:239-261-2266
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082727174400000X
IL036082727207RC0000X
FLME143903207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082727Medicaid
IL060067999OtherRAILROAD
ILE02473Medicare UPIN
ILL92410Medicare ID - Type Unspecified
IL214881Medicare Oscar/Certification