Provider Demographics
NPI:1417027061
Name:DWIVEDI, RAJ H (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJ
Middle Name:H
Last Name:DWIVEDI
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 1:623 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257
Mailing Address - Country:US
Mailing Address - Phone:559-781-2403
Mailing Address - Fax:559-781-4334
Practice Address - Street 1:623 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257
Practice Address - Country:US
Practice Address - Phone:559-781-2403
Practice Address - Fax:559-781-4334
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A337030208600000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A337030Medicaid
00A337030Medicare ID - Type Unspecified
CA00A337030Medicaid