Provider Demographics
NPI:1346242872
Name:RAJADAS, PHILLIP THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:THOMAS
Last Name:RAJADAS
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 8867
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-8867
Mailing Address - Country:US
Mailing Address - Phone:719-561-5377
Mailing Address - Fax:719-561-5378
Practice Address - Street 1:201 S MCCULLOCH BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-2892
Practice Address - Country:US
Practice Address - Phone:719-561-5377
Practice Address - Fax:719-561-5378
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39112208100000X, 2081P2900X
KS04-316522081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00281502OtherRR MEDICARE
KS200362640AMedicaid
CO13777777Medicaid
G83798Medicare UPIN
KS105093Medicare PIN
CO4G2598Medicare ID - Type Unspecified
CO13777777Medicaid