Provider Demographics
NPI:1326683186
Name:RAJA, PAVANKUMAR (DPT)
Entity Type:Individual
Prefix:
First Name:PAVANKUMAR
Middle Name:
Last Name:RAJA
Suffix:
Gender:M
Credentials:DPT
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 419666
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-9666
Mailing Address - Country:US
Mailing Address - Phone:410-970-8190
Mailing Address - Fax:
Practice Address - Street 1:3165 CRAIN HWY STE 100
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4847
Practice Address - Country:US
Practice Address - Phone:301-885-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist