Provider Demographics
NPI:1407018484
Name:RAJENDRAN, AMANDA MATHIAS (DO)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MATHIAS
Last Name:RAJENDRAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:MARGARET
Other - Last Name:MATHIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:385 WIRTZ DR.
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-6118
Mailing Address - Country:US
Mailing Address - Phone:815-306-2777
Mailing Address - Fax:815-306-2778
Practice Address - Street 1:385 WIRTZ DR.
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-6118
Practice Address - Country:US
Practice Address - Phone:815-306-2777
Practice Address - Fax:815-306-2778
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-131509207Q00000X
IL036131509207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine