Provider Demographics
NPI:1376571018
Name:RAJASEKARAN, PAKKAM R (MD)
Entity Type:Individual
Prefix:
First Name:PAKKAM
Middle Name:R
Last Name:RAJASEKARAN
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 1:214 KING ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1142
Mailing Address - Country:US
Mailing Address - Phone:315-713-5211
Mailing Address - Fax:315-393-5781
Practice Address - Street 1:214 KING ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1142
Practice Address - Country:US
Practice Address - Phone:315-713-5211
Practice Address - Fax:315-393-5781
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1469452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00703493Medicaid
MEMM5126Medicare ID - Type Unspecified