Provider Demographics
NPI:1376532556
Name:RAJ, ETHIRAJ GOVINDA (MD)
Entity Type:Individual
Prefix:
First Name:ETHIRAJ
Middle Name:GOVINDA
Last Name:RAJ
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 1:1165 S LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3406
Mailing Address - Country:US
Mailing Address - Phone:810-732-5400
Mailing Address - Fax:810-733-1624
Practice Address - Street 1:1165 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3406
Practice Address - Country:US
Practice Address - Phone:810-732-5400
Practice Address - Fax:810-733-1624
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1100482OtherHEALTH PLUS OF MICHIGAN
MIER039365OtherSTATE LICENSE NUMBER
MI0B51240, ER039365OtherBLUE CARE NETWORK
MIC1855OtherMCARE
MI1010892OtherMCLAREN HEALTH PLAN
MI0B51240OtherBLUE CROSS BLUE SHIELD MI
MI1010892OtherMCLAREN HEALTH ADVANTAGE
MI4591753Medicaid
MI1010892OtherMCLAREN HEALTH PLAN
MIER039365OtherSTATE LICENSE NUMBER