Provider Demographics
NPI:1417280017
Name:VEGESNA, RAJ VISWANADH (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJ
Middle Name:VISWANADH
Last Name:VEGESNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:VISWANADH
Other - Middle Name:RAJU
Other - Last Name:VEGESNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1217 KEARNEY STREET
Mailing Address - Street 2:STE 2
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-990-8302
Mailing Address - Fax:810-990-8402
Practice Address - Street 1:1217 KEARNEY STREET
Practice Address - Street 2:STE 2
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-990-8302
Practice Address - Fax:810-990-8402
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094437207R00000X
MI43010944377208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine