Provider Demographics
NPI:1326022526
Name:RAJALA, MARY M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:RAJALA
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 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-4050
Mailing Address - Fax:262-782-6040
Practice Address - Street 1:225 S EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4257
Practice Address - Country:US
Practice Address - Phone:262-787-4050
Practice Address - Fax:262-782-6040
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35169-020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31996300Medicaid
WI07592Medicare ID - Type UnspecifiedPROVIDER NUMBER
WIF39601Medicare UPIN
0013-07855Medicare PIN
WI07855Medicare ID - Type UnspecifiedPROVIDER NUMBER